Healthcare Provider Details

I. General information

NPI: 1518291384
Provider Name (Legal Business Name): KEVIN A ROUSH CST FA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 09/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 FAIRVIEW AVE
CASPER WY
82609-2907
US

IV. Provider business mailing address

2211 FAIRVIEW AVE
CASPER WY
82609-2907
US

V. Phone/Fax

Practice location:
  • Phone: 307-277-3209
  • Fax: 307-472-1881
Mailing address:
  • Phone: 307-277-3209
  • Fax: 307-472-1881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: