=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093953259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAMERON SCOTT CUSHENBERY CRNA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2009
-----------------------------------------------------
Last Update Date | 02/05/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3910 CHARTER HOUSE DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32224-7797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-703-4829
-----------------------------------------------------
Fax | 904-232-8559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3910 CHARTER HOUSE DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32224-7797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-703-4829
-----------------------------------------------------
Fax | 904-232-8559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | ARNP9207716
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------