Healthcare Provider Details

I. General information

NPI: 1043561004
Provider Name (Legal Business Name): JUSTIN ROBERT CUSICK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2012
Last Update Date: 09/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8990 SPRINGBROOK DR NW STE 250
COON RAPIDS MN
55433-5884
US

IV. Provider business mailing address

3514 CHERRY LN UNIT A
WOODBURY MN
55129-8794
US

V. Phone/Fax

Practice location:
  • Phone: 763-398-1176
  • Fax:
Mailing address:
  • Phone: 651-335-1665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR160593-8
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number091716
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: