Provider Demographics
NPI:1164823712
Name:JANZEN, DUSTIN WAYNE (LSA)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:WAYNE
Last Name:JANZEN
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2967 OAK RUN PKWY
Mailing Address - Street 2:STE 505, RM #12
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78132-5379
Mailing Address - Country:US
Mailing Address - Phone:210-598-2800
Mailing Address - Fax:
Practice Address - Street 1:2967 OAK RUN PKWY STE 505
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78132-5379
Practice Address - Country:US
Practice Address - Phone:210-598-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00555246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154639OtherNBSTSA BOARD CERTIFICATION
TX1234OtherCERTIFICATION - OPA-C
TXSA00555OtherLSA LICENSE