Provider Demographics
NPI:1962018150
Name:OMELAYENKO, SERGIY (CRNA)
Entity Type:Individual
Prefix:
First Name:SERGIY
Middle Name:
Last Name:OMELAYENKO
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 1:21502 NORTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33549-4195
Mailing Address - Country:US
Mailing Address - Phone:813-451-5940
Mailing Address - Fax:
Practice Address - Street 1:21502 NORTHWOOD DR
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33549-4195
Practice Address - Country:US
Practice Address - Phone:813-451-5940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-22
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9267898163W00000X
SC26559367500000X
FL11010653367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty