Provider Demographics
NPI:1396847638
Name:LUSSENDEN, RANDELL CRAIG (CRNA)
Entity Type:Individual
Prefix:
First Name:RANDELL
Middle Name:CRAIG
Last Name:LUSSENDEN
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:PO BOX 660
Mailing Address - Street 2:400 EAST FIRST STREET
Mailing Address - City:MORRIS
Mailing Address - State:MN
Mailing Address - Zip Code:56267-0660
Mailing Address - Country:US
Mailing Address - Phone:320-589-1313
Mailing Address - Fax:320-589-3533
Practice Address - Street 1:400 EAST FIRST STREET
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:MN
Practice Address - Zip Code:56267-0660
Practice Address - Country:US
Practice Address - Phone:320-589-1313
Practice Address - Fax:320-589-3533
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0919104367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered