Provider Demographics
NPI:1437168911
Name:GEORGETTE, NATHANIEL (CRNA)
Entity Type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:GEORGETTE
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 1:111 CLOCK TOWER COMMONS
Mailing Address - Street 2:ROUTE 22
Mailing Address - City:BREWSTER
Mailing Address - State:NY
Mailing Address - Zip Code:10509-4055
Mailing Address - Country:US
Mailing Address - Phone:845-592-4915
Mailing Address - Fax:845-279-5168
Practice Address - Street 1:330 HOLLY HILL LN
Practice Address - Street 2:
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-4685
Practice Address - Country:US
Practice Address - Phone:203-910-0556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2015-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT65314367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT65314OtherLICENSE
CTP00350616OtherRAILROAD MEDICARE
CTP00350616OtherRAILROAD MEDICARE