Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 12010669A | IN |
NPI | 1033207329 |
---|---|
Provider Name | Dr. Marykate Rusnak |
First Address | Fort Collins, CO 80525 |
Second Address | Fort Collins, CO 80525 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2006 |
Last Update Date | 07/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200826610 | (05) | IN |