Provider Demographics
NPI:1124046024
Name:NIEWIEROSKI, WILLIAM J JR (CRNA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:J
Last Name:NIEWIEROSKI
Suffix:JR
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 1:445 FACTORY ST
Mailing Address - Street 2:PO BOX 91
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2729
Mailing Address - Country:US
Mailing Address - Phone:315-782-4207
Mailing Address - Fax:315-782-8699
Practice Address - Street 1:830 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4066
Practice Address - Country:US
Practice Address - Phone:315-785-8509
Practice Address - Fax:315-785-8619
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277507367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR58402Medicare UPIN
NYDD3313Medicare PIN