Basic Information
| Provider Information | |||||||||
| NPI: | 1356573471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIGORIEV | ||||||||
| FirstName: | LANA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 FEDERAL ST STE SW200 | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563564924 | ||||||||
| FaxNumber: | 8563564710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 COOPER PLZ | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422425 | ||||||||
| FaxNumber: | 8569688239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2009 | ||||||||
| LastUpdateDate: | 03/07/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 26NR13178600 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 367500000X | 26NR13178600 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | NJ00235700 | 01 | NJ | STATE LICENSE | OTHER |