Provider Demographics
NPI:1306977194
Name:FEDORCHAK, BRIAN A (CRNA)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:FEDORCHAK
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 1:1906 BELLEVIEW AVE SE
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1838
Mailing Address - Country:US
Mailing Address - Phone:540-853-0222
Mailing Address - Fax:540-981-7855
Practice Address - Street 1:1906 BELLEVIEW AVE SE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014
Practice Address - Country:US
Practice Address - Phone:540-853-0222
Practice Address - Fax:540-981-7855
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168517367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR123817OtherLICENSE