Healthcare Provider Details

I. General information

NPI: 1922517820
Provider Name (Legal Business Name): KYLE RICHARD LUSK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 09/19/2021
Certification Date: 09/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 SUDDERTH DR
RUIDOSO NM
88345-6043
US

IV. Provider business mailing address

137 DANCING STAR TRL
ALTO NM
88312-9522
US

V. Phone/Fax

Practice location:
  • Phone: 575-257-8200
  • Fax:
Mailing address:
  • Phone: 575-937-8303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number251088
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA-01535
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: