Provider Demographics
NPI:1760475776
Name:TRUESDALE, KENNETH (CRNA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:TRUESDALE
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:PO BOX 67
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07033-0067
Mailing Address - Country:US
Mailing Address - Phone:201-487-7227
Mailing Address - Fax:
Practice Address - Street 1:1 CLARA MAASS DR
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-3550
Practice Address - Country:US
Practice Address - Phone:973-450-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00205400367500000X
NJ26N009116700367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ022403A3RMedicare ID - Type Unspecified