Provider Demographics
NPI:1578035879
Name:RUST, NICHOLAS CHARLES (CRNA)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:CHARLES
Last Name:RUST
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 1:1 SYCAMORE ST APT 137
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-2622
Mailing Address - Country:US
Mailing Address - Phone:812-827-6409
Mailing Address - Fax:
Practice Address - Street 1:1421 N 7TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1005
Practice Address - Country:US
Practice Address - Phone:812-232-7192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-26
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28213636A163W00000X
IN124319367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse