Provider Demographics
NPI:1992088298
Name:KUZMIAK, ADAM JEREMIAH (CRNA)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:JEREMIAH
Last Name:KUZMIAK
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 1:3724 W ASHTON CT
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-2761
Mailing Address - Country:US
Mailing Address - Phone:623-249-4207
Mailing Address - Fax:
Practice Address - Street 1:3724 W ASHTON CT
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086-2761
Practice Address - Country:US
Practice Address - Phone:623-249-4207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN127736163W00000X
AZCRNA0794207L00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ148617OtherMEDICARE PTAN
AZ664809Medicaid