Provider Demographics
NPI:1386647337
Name:PETRUSCH, EDWARD K (CRNA)
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:K
Last Name:PETRUSCH
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 1:444 COLLETT BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ALVATON
Mailing Address - State:KY
Mailing Address - Zip Code:42122-9675
Mailing Address - Country:US
Mailing Address - Phone:270-842-0433
Mailing Address - Fax:
Practice Address - Street 1:444 COLLETT BRIDGE RD
Practice Address - Street 2:
Practice Address - City:ALVATON
Practice Address - State:KY
Practice Address - Zip Code:42122-9675
Practice Address - Country:US
Practice Address - Phone:270-842-0433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY820A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered