Provider Demographics
NPI:1013022284
Name:DUSENBERY, JOHN D (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:D
Last Name:DUSENBERY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 TERRACE CT
Mailing Address - Street 2:
Mailing Address - City:TWO RIVERS
Mailing Address - State:WI
Mailing Address - Zip Code:54241-1720
Mailing Address - Country:US
Mailing Address - Phone:920-794-7651
Mailing Address - Fax:
Practice Address - Street 1:5000 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:TWO RIVERS
Practice Address - State:WI
Practice Address - Zip Code:54241-3900
Practice Address - Country:US
Practice Address - Phone:920-794-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI78062-030367500000X
WI380-033367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered