Healthcare Provider Details

I. General information

NPI: 1790340974
Provider Name (Legal Business Name): PAUL KISUCKY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 S WALNUT ST
LAS CRUCES NM
88001-3955
US

IV. Provider business mailing address

205 W BOUTZ RD BLDG 1
LAS CRUCES NM
88005-3259
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-6330
  • Fax:
Mailing address:
  • Phone: 575-532-7033
  • Fax: 575-556-7139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PAUL J KISUCKY III
Title or Position: OWNER
Credential: CRNA
Phone: 915-301-5091