Provider Demographics
NPI:1043561004
Name:CUSICK, JUSTIN ROBERT (CRNA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:ROBERT
Last Name:CUSICK
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 1:3514 CHERRY LN UNIT A
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-8794
Mailing Address - Country:US
Mailing Address - Phone:651-335-1665
Mailing Address - Fax:
Practice Address - Street 1:8990 SPRINGBROOK DR NW STE 250
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-5884
Practice Address - Country:US
Practice Address - Phone:763-398-1176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-30
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR160593-8163W00000X
MN091716367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered