Provider Demographics
NPI:1043315856
Name:SLEZAK, MICHAEL T (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:T
Last Name:SLEZAK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 OLD BEST RD
Mailing Address - Street 2:
Mailing Address - City:NASSAU
Mailing Address - State:NY
Mailing Address - Zip Code:12123-2914
Mailing Address - Country:US
Mailing Address - Phone:518-766-4012
Mailing Address - Fax:
Practice Address - Street 1:2215 BURDETT AVENUE
Practice Address - Street 2:SAMARITAN HOSPITAL
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180
Practice Address - Country:US
Practice Address - Phone:518-271-3258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY255656-1367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400061442Medicare PIN
R75355Medicare UPIN