Provider Demographics
NPI:1669440020
Name:LULGJURAJ, MARY (CRNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LULGJURAJ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 TOWN CENTER DR
Mailing Address - Street 2:STE 203
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:248-585-8221
Mailing Address - Fax:248-585-8270
Practice Address - Street 1:44201 DEQUINDRE
Practice Address - Street 2:400 FSC - PCS
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1198
Practice Address - Country:US
Practice Address - Phone:248-423-3144
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2017-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704221264367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI430F364420OtherBCBSM
MI4684600Medicaid
MI430F364420OtherBCBSM
MI4684600Medicaid