Provider Demographics
NPI:1538856620
Name:EVTODIENCO, SERGHEI ALEXANDR (CRNA)
Entity type:Individual
Prefix:
First Name:SERGHEI
Middle Name:ALEXANDR
Last Name:EVTODIENCO
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 1:5000 W ESPLANADE AVE # 610
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2570
Mailing Address - Country:US
Mailing Address - Phone:504-994-4691
Mailing Address - Fax:
Practice Address - Street 1:4200 HOUMA BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2970
Practice Address - Country:US
Practice Address - Phone:504-503-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229875367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered