Healthcare Provider Details

I. General information

NPI: 1871253369
Provider Name (Legal Business Name): JEFFREY GEORGE CUSSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2021
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2823 FRESNO ST
FRESNO CA
93721-1324
US

IV. Provider business mailing address

1520 CARBURY WAY
ROSEVILLE CA
95747-7034
US

V. Phone/Fax

Practice location:
  • Phone: 559-459-6000
  • Fax:
Mailing address:
  • Phone: 916-899-9988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001648
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: