Basic Information
| Provider Information | |||||||||
| NPI: | 1093373458 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | NISTRIAN | ||||||||
| FirstName: | EMANUEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 MEDICAL CENTER PKWY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043308160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076221959 | ||||||||
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| Practice Location | |||||||||
| Address1: | KENNEBEC ANESTHESIA ASSOCIATES, P.A. | ||||||||
| Address2: | 35 MEDICAL CENTER PKWY | ||||||||
| City: | AUGUSTA | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043308160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2076221959 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2019 | ||||||||
| LastUpdateDate: | 11/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 60309732 | WA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367500000X | RNA21366 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.