Provider Demographics
NPI:1700162518
Name:KUSTERMANN, PAUL ANTHONY
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ANTHONY
Last Name:KUSTERMANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:929 DUCHESS LN
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-8915
Mailing Address - Country:US
Mailing Address - Phone:952-891-5713
Mailing Address - Fax:
Practice Address - Street 1:929 DUCHESS LN
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-8915
Practice Address - Country:US
Practice Address - Phone:952-891-5713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-25
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1019588171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor