Provider Demographics
NPI:1881380491
Name:SIUTSOU, PAVEL (CRNA)
Entity type:Individual
Prefix:
First Name:PAVEL
Middle Name:
Last Name:SIUTSOU
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 1:135 STANIE GLEN RD
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-6235
Mailing Address - Country:US
Mailing Address - Phone:862-754-6151
Mailing Address - Fax:
Practice Address - Street 1:135 STANIE GLEN RD
Practice Address - Street 2:
Practice Address - City:WATCHUNG
Practice Address - State:NJ
Practice Address - Zip Code:07069-6235
Practice Address - Country:US
Practice Address - Phone:862-754-6151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14852700367500000X
NY793635-01163W00000X
NJ26NR15434100163W00000X
NY793635367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse