Provider Demographics
NPI:1316488422
Name:PERISSINOTTI, ADAM JOSEPH (CRNA)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:JOSEPH
Last Name:PERISSINOTTI
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 1:1212 CARRIAGE LANE
Mailing Address - Street 2:
Mailing Address - City:LASALLE
Mailing Address - State:ONTARIO
Mailing Address - Zip Code:N9H 1Z8
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4201 SAINT ANTOINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2153
Practice Address - Country:US
Practice Address - Phone:313-745-3330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-09
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN200965-6163W00000X
MI4704285098163W00000X, 367500000X
DCRN1033014163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse