Provider Demographics
NPI:1093953259
Name:CUSHENBERY, CAMERON SCOTT (CRNA)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:SCOTT
Last Name:CUSHENBERY
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 1:3910 CHARTER HOUSE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-7797
Mailing Address - Country:US
Mailing Address - Phone:904-703-4829
Mailing Address - Fax:904-232-8559
Practice Address - Street 1:3910 CHARTER HOUSE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-7797
Practice Address - Country:US
Practice Address - Phone:904-703-4829
Practice Address - Fax:904-232-8559
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9207716367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA902227421AMedicaid
FL0006927-00Medicaid
FLBK677ZMedicare PIN
GA902227421AMedicaid