Provider Demographics
NPI:1669604880
Name:PRUSAK, MARA PATRICIA (RN, CRNA)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:PATRICIA
Last Name:PRUSAK
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S # MS 21110Q
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:DULUTH CLINIC
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-4150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-21
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1652813367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered