Provider Demographics
NPI:1942944012
Name:MICTIL, GIOVANNI ANTONIO (MSN - CRNA)
Entity Type:Individual
Prefix:
First Name:GIOVANNI
Middle Name:ANTONIO
Last Name:MICTIL
Suffix:
Gender:M
Credentials:MSN - CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66-4 CALLE 53
Mailing Address - Street 2:
Mailing Address - City:CAROLINA
Mailing Address - State:PR
Mailing Address - Zip Code:00985-4926
Mailing Address - Country:US
Mailing Address - Phone:787-233-5986
Mailing Address - Fax:
Practice Address - Street 1:66-4 CALLE 53
Practice Address - Street 2:
Practice Address - City:CAROLINA
Practice Address - State:PR
Practice Address - Zip Code:00985-4926
Practice Address - Country:US
Practice Address - Phone:787-233-5986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY720306367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered