Provider Demographics
NPI:1205464005
Name:STACZEK, CHRISTOPHER ALEXANDER (CRNA)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:ALEXANDER
Last Name:STACZEK
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 1:12715 GENEVA GLADE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-7606
Mailing Address - Country:US
Mailing Address - Phone:407-970-5620
Mailing Address - Fax:
Practice Address - Street 1:520 S LAKE FORMOSA DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1867
Practice Address - Country:US
Practice Address - Phone:407-970-5620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2021-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11013432367500000X
FLRN9385383163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse