Provider Demographics
NPI:1285093351
Name:PUTHIYOTTIL, SAJA C (CRNA)
Entity type:Individual
Prefix:
First Name:SAJA
Middle Name:C
Last Name:PUTHIYOTTIL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 RIVERSIDE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1500
Mailing Address - Country:US
Mailing Address - Phone:608-362-7444
Mailing Address - Fax:608-362-0417
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:ATTN: ANESTHESIA DEPT
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-2230
Practice Address - Country:US
Practice Address - Phone:608-364-5355
Practice Address - Fax:608-362-0417
Is Sole Proprietor?:No
Enumeration Date:2016-02-18
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIF0216734363LF0000X
WI6833-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1285093351Medicaid