Provider Demographics
NPI:1922517820
Name:LUSK, KYLE RICHARD (CRNA)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:RICHARD
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 1:137 DANCING STAR TRL
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:NM
Mailing Address - Zip Code:88312-9522
Mailing Address - Country:US
Mailing Address - Phone:575-937-8303
Mailing Address - Fax:
Practice Address - Street 1:211 SUDDERTH DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-6043
Practice Address - Country:US
Practice Address - Phone:575-257-8200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-22
Last Update Date:2021-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ251088367500000X
NMCRNA-01535367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty