Provider Demographics
NPI:1487659587
Name:RUSTAD, DEBRA ANN (RN, CNP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:ANN
Last Name:RUSTAD
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3850 PARK NICOLLET BLVD
Practice Address - Street 2:PARK NICOLLET CLINIC--SENIOR SERVICES-- 3RD FLOOR
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-2527
Practice Address - Country:US
Practice Address - Phone:952-993-5041
Practice Address - Fax:952-993-3236
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR092748-4363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN090529100Medicaid
MN090529100Medicaid
MN50002903Medicare ID - Type Unspecified