Provider Demographics
NPI:1417266529
Name:CANUSO, REGINA
Entity Type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:CANUSO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 E WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1173
Mailing Address - Country:US
Mailing Address - Phone:315-426-3600
Mailing Address - Fax:315-426-7757
Practice Address - Street 1:1330 E WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1173
Practice Address - Country:US
Practice Address - Phone:315-426-3600
Practice Address - Fax:315-426-7757
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY462595364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult