Provider Demographics
NPI:1376145615
Name:RUSIN, WALTER MIECZYSLAW (MEDICAL STUDENT)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:MIECZYSLAW
Last Name:RUSIN
Suffix:
Gender:M
Credentials:MEDICAL STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 W MEADOW AVE
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1169
Mailing Address - Country:US
Mailing Address - Phone:612-245-3813
Mailing Address - Fax:
Practice Address - Street 1:4711 W MEADOW AVE
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1169
Practice Address - Country:US
Practice Address - Phone:612-245-3813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program