Provider Demographics
NPI:1295073781
Name:VERMEULEN, JUSTIN M (CRNA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:VERMEULEN
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 1:1373 E STATE ROAD 62
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-7328
Mailing Address - Country:US
Mailing Address - Phone:812-801-0800
Mailing Address - Fax:
Practice Address - Street 1:8212 SUMMA AVE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3421
Practice Address - Country:US
Practice Address - Phone:225-769-4403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016642367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300060135Medicaid
KY7100788650Medicaid