Provider Demographics
NPI:1174876577
Name:AIZIGOV, RONI (CRNA, NP-C)
Entity type:Individual
Prefix:
First Name:RONI
Middle Name:
Last Name:AIZIGOV
Suffix:
Gender:M
Credentials:CRNA, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50653 HOLLYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-4947
Mailing Address - Country:US
Mailing Address - Phone:718-208-0446
Mailing Address - Fax:574-244-0240
Practice Address - Street 1:51050 BITTERSWEET RD STE B
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-7879
Practice Address - Country:US
Practice Address - Phone:718-208-0446
Practice Address - Fax:574-244-0240
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71011097A363L00000X
IN28206614A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner