Provider Demographics
NPI:1871599696
Name:DOHERTY, JOHN HENRY (CRNA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:HENRY
Last Name:DOHERTY
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 1:300 COMMUNITY DRIVE
Mailing Address - Street 2:NAPA
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030
Mailing Address - Country:US
Mailing Address - Phone:516-626-6366
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DRIVE
Practice Address - Street 2:NAPA
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030
Practice Address - Country:US
Practice Address - Phone:516-526-4887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334669367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYR0A861Medicare ID - Type Unspecified