Provider Demographics
NPI:1134232077
Name:YOUNG, ANICIA BOUTIN (CRNA)
Entity type:Individual
Prefix:
First Name:ANICIA
Middle Name:BOUTIN
Last Name:YOUNG
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 1:163 BILTON RD
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-1067
Mailing Address - Country:US
Mailing Address - Phone:860-306-9717
Mailing Address - Fax:860-763-4111
Practice Address - Street 1:55 ST GEORGE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104
Practice Address - Country:US
Practice Address - Phone:413-736-7463
Practice Address - Fax:413-736-7466
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049381367500000X
MARN197541367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANA078006Medicare PIN
CT430000253Medicare ID - Type UnspecifiedANESTHESIA