Provider Demographics
NPI:1679650402
Name:LUSK, SHAWN DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:DAVID
Last Name:LUSK
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 1:5840 DAVIS CREEK RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1004
Mailing Address - Country:US
Mailing Address - Phone:304-736-6126
Mailing Address - Fax:304-736-1531
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-526-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV54493163W00000X
WV075642367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVQ47421AMedicare PIN