Healthcare Provider Details

I. General information

NPI: 1558042622
Provider Name (Legal Business Name): RYAN K HURSH APRN, CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 08/15/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 SKYLINE BLVD
CLOQUET MN
55720-1164
US

IV. Provider business mailing address

512 SKYLINE BLVD
CLOQUET MN
55720-3787
US

V. Phone/Fax

Practice location:
  • Phone: 218-879-1271
  • Fax: 218-879-8904
Mailing address:
  • Phone: 218-879-1271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10355
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10355
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: