Basic Information
| Provider Information | |||||||||
| NPI: | 1538115951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROSSNOE | ||||||||
| FirstName: | CHETLEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4515 MARSHA SHARP FWY | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794072520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067447223 | ||||||||
| FaxNumber: | 8067403325 | ||||||||
| Practice Location | |||||||||
| Address1: | 4515 MARSHA SHARP FWY | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794072520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067447223 | ||||||||
| FaxNumber: | 8067403325 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | M0696 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 175472304 | 05 | TX | MEDICAID | 148450101 | 01 | TX | TEAM CHOICE CORE (GRACE CLINIC) | OTHER | 148450101 | 01 | TX | FIRSTCARE (GRACE CLINIC) | OTHER | 7495745 | 01 | TX | AETNA | OTHER | 8V8692 | 01 | TX | BCBS (GRACE CLINIC) | OTHER |