Provider Demographics
NPI:1780257659
Name:GRISHCHUK, DMITRIY ALEX (CRNA)
Entity type:Individual
Prefix:MR
First Name:DMITRIY
Middle Name:ALEX
Last Name:GRISHCHUK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:MR
Other - First Name:DMITRIY
Other - Middle Name:ALEX
Other - Last Name:GRISHCHUK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:1235 E CHEROKEE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2203
Mailing Address - Country:US
Mailing Address - Phone:417-820-6863
Mailing Address - Fax:
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-820-6863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021022262367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered