Provider Demographics
NPI:1528152915
Name:RUSK, SUZANNE S (PNP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:S
Last Name:RUSK
Suffix:
Gender:F
Credentials:PNP
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 9372
Mailing Address - Street 2:FAIRVIEW HEALTH SERVICES
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-9372
Mailing Address - Country:US
Mailing Address - Phone:612-672-2294
Mailing Address - Fax:612-672-6041
Practice Address - Street 1:5200 FAIRVIEW BOULEVARD
Practice Address - Street 2:FAIRVIEW LAKES PEDIATRICS
Practice Address - City:WYOMING
Practice Address - State:MN
Practice Address - Zip Code:55092
Practice Address - Country:US
Practice Address - Phone:651-682-7340
Practice Address - Fax:651-982-7349
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-111703-1363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM42088721Medicaid
NM42088721Medicaid
348308801Medicare ID - Type Unspecified