Healthcare Provider Details

I. General information

NPI: 1194089805
Provider Name (Legal Business Name): GARY WILSON BARSUASKAS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4677 VALLEY WEST BLVD.
ARCATA CA
95521
US

IV. Provider business mailing address

PO BOX 362
CUTTEN CA
95534
US

V. Phone/Fax

Practice location:
  • Phone: 707-822-5244
  • Fax: 707-822-5442
Mailing address:
  • Phone: 707-616-9086
  • Fax: 707-822-5442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number582770/12889
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number582770/12889
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: