Provider Demographics
NPI:1083275085
Name:HANOVICH, NATHAN BRYAN (CRNA)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:BRYAN
Last Name:HANOVICH
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 1:172 GARDEN CT
Mailing Address - Street 2:
Mailing Address - City:WHITMORE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48189-9490
Mailing Address - Country:US
Mailing Address - Phone:734-353-9416
Mailing Address - Fax:
Practice Address - Street 1:401 W GREENLAWN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2819
Practice Address - Country:US
Practice Address - Phone:517-975-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704295543367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered