Healthcare Provider Details

I. General information

NPI: 1053140723
Provider Name (Legal Business Name): JUSTIN LOUIS RAGUSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 MAIN ST 326 WENDE HALL
BUFFALO NY
14214-3099
US

IV. Provider business mailing address

3435 MAIN ST 326 WENDE HALL
BUFFALO NY
14214-3099
US

V. Phone/Fax

Practice location:
  • Phone: 716-829-3204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number751349
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: