Healthcare Provider Details

I. General information

NPI: 1063282994
Provider Name (Legal Business Name): RANDY WAYNE LASUT JR. CRNP FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4186 CORTLAND DR
NEW PARIS PA
15554-7706
US

IV. Provider business mailing address

4186 CORTLAND DR
NEW PARIS PA
15554-7706
US

V. Phone/Fax

Practice location:
  • Phone: 814-839-4108
  • Fax:
Mailing address:
  • Phone: 814-839-4108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP029010
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: