Provider Demographics
NPI:1154086643
Name:KOUANANG, BORIS G (CRNA)
Entity Type:Individual
Prefix:
First Name:BORIS
Middle Name:G
Last Name:KOUANANG
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 1:200 BOYDEN AVE APT 374
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-2685
Mailing Address - Country:US
Mailing Address - Phone:609-218-7884
Mailing Address - Fax:
Practice Address - Street 1:94 OLD SHORT HILLS RD STE 1
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5668
Practice Address - Country:US
Practice Address - Phone:973-322-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01224000367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered