Provider Demographics
NPI:1659365658
Name:ROUSSEL, JOHN (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ROUSSEL
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 1:6601 ARBOR RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-7745
Mailing Address - Country:US
Mailing Address - Phone:502-931-9962
Mailing Address - Fax:502-561-4221
Practice Address - Street 1:3605 NORTHGATE CT
Practice Address - Street 2:STE 101
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6400
Practice Address - Country:US
Practice Address - Phone:812-944-4263
Practice Address - Fax:812-944-1166
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2014-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28152575A163W00000X
KY47452367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200363700Medicaid
KYP50775Medicare UPIN
IN232380NMedicare Oscar/Certification
IN200363700Medicaid
INCB9200Medicare ID - Type Unspecified