Provider Demographics
NPI:1588620454
Name:CROFUT, NICHOLAS (CRNA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:CROFUT
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 1:806 GREENWICH DR
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-2412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30200 TELEGRAPH RD
Practice Address - Street 2:SUITE 220
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4502
Practice Address - Country:US
Practice Address - Phone:248-258-5058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704236483367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00293187OtherRAILROAD MEDICARE
MI104822930Medicaid
MIN47230082Medicare UPIN
MIN78650071Medicare ID - Type UnspecifiedLOC 01
MIP00293187Medicare PIN