Provider Demographics
NPI:1760529440
Name:JUSTIN, RONALD M (CRNA)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:M
Last Name:JUSTIN
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 116
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48707-0116
Mailing Address - Country:US
Mailing Address - Phone:989-894-3820
Mailing Address - Fax:989-891-0497
Practice Address - Street 1:1900 COLUMBUS AVE
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48708-6831
Practice Address - Country:US
Practice Address - Phone:989-894-3820
Practice Address - Fax:989-891-0497
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2010-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704097573367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4308754130OtherBCBS
MI4851665Medicaid
MI4851665Medicaid