Healthcare Provider Details

I. General information

NPI: 1205474962
Provider Name (Legal Business Name): JUSTIN WAYNE MALINOSKY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2019
Last Update Date: 03/22/2023
Certification Date: 03/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8 PROSPECT ST
NASHUA NH
03060-3925
US

IV. Provider business mailing address

12 DWYER ST
MERRIMACK NH
03054-2321
US

V. Phone/Fax

Practice location:
  • Phone: 603-577-2000
  • Fax:
Mailing address:
  • Phone: 208-890-1177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1624819
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number082089-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: