Provider Demographics
NPI:1801017363
Name:PROUTY, AMY MARIE (CRNA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MARIE
Last Name:PROUTY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MARIE
Other - Last Name:SAYADZAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:622 W 168TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3720
Mailing Address - Country:US
Mailing Address - Phone:212-305-9878
Mailing Address - Fax:212-305-8980
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-9878
Practice Address - Fax:212-305-8980
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2010-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY629684367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216737020Medicare PIN
ILK53033Medicare PIN
ILK47579Medicare PIN
ILK25494Medicare PIN
IL214656002Medicare PIN
ILK50928Medicare PIN