Provider Demographics
NPI:1528143583
Name:LUSK, STEPHEN KEITH (APRN-CRNA)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:KEITH
Last Name:LUSK
Suffix:
Gender:M
Credentials:APRN-CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3204 VIRGINIA AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304
Mailing Address - Country:US
Mailing Address - Phone:304-342-7878
Mailing Address - Fax:304-388-3604
Practice Address - Street 1:501 MORRIS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1326
Practice Address - Country:US
Practice Address - Phone:304-388-6220
Practice Address - Fax:304-388-3604
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2019-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN54395367500000X
WV70061367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00087015Medicaid
WV2602990000Medicaid
WV2602990000Medicaid