Basic Information
| Provider Information | |||||||||
| NPI: | 1285115840 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KRASSILNIK | ||||||||
| FirstName: | NINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1407 UNION AVE STE 700 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381043641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668622 | ||||||||
| FaxNumber: | 9013022622 | ||||||||
| Practice Location | |||||||||
| Address1: | 930 MADISON AVE FL 5 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381037401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018668013 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2018 | ||||||||
| LastUpdateDate: | 10/08/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 57058 | TN | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | Q038590 | 05 | TN | MEDICAID |