Provider Demographics
NPI:1629631148
Name:TIWARI, SUSHANT (CRNA)
Entity Type:Individual
Prefix:
First Name:SUSHANT
Middle Name:
Last Name:TIWARI
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 1:4437 COLONY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7843
Mailing Address - Country:US
Mailing Address - Phone:561-685-0381
Mailing Address - Fax:
Practice Address - Street 1:5352 LINTON BLVD
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-6514
Practice Address - Country:US
Practice Address - Phone:561-498-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002822367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered