Provider Demographics
NPI:1457389868
Name:POLECHETTI, JOHN SAMUEL (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:SAMUEL
Last Name:POLECHETTI
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 1:555 PINE ST
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-5547
Mailing Address - Country:US
Mailing Address - Phone:716-465-0222
Mailing Address - Fax:
Practice Address - Street 1:1408 SWEET HOME RD STE 9
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14228-2783
Practice Address - Country:US
Practice Address - Phone:716-243-8377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3315571367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
BB3304Medicare ID - Type Unspecified