Provider Demographics
NPI:1629790647
Name:EWANOWSKI, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EWANOWSKI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 S 800 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1785
Mailing Address - Country:US
Mailing Address - Phone:801-641-2791
Mailing Address - Fax:
Practice Address - Street 1:2500 ROCKY MOUNTAIN AVE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-9004
Practice Address - Country:US
Practice Address - Phone:970-624-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-15
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10197649-3102163W00000X
COC-APN.0100302-C-CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse