MEDICARE: JAYSON MARK MICHNOWICZ CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	367500000X	Certified Registered Nurse Anesthetist	264937	NC

General Provider Information

NPI Number	:	1811329816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAYSON MARK MICHNOWICZ CRNA

Provider Business Mailing Address
First Line	:	1116 VALLEY ROSE WAY
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27712-2994
Country	:	US
Telephone Number	:	618-420-5903
Fax Number	:

Provider Business Practice Location Address
First Line	:	1116 VALLEY ROSE WAY
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27712-2994
Country	:	US
Telephone Number	:	618-420-5903
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2013
Last Update Date	:	11/21/2022

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