Healthcare Provider Details

I. General information

NPI: 1386354777
Provider Name (Legal Business Name): JUSTIN LASURE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 S CENTER AVE
SOMERSET PA
15501-2033
US

IV. Provider business mailing address

PO BOX 150
MEYERSDALE PA
15552-0150
US

V. Phone/Fax

Practice location:
  • Phone: 814-443-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number98303
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN670587
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number115510
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: