Basic Information
Provider Information | |||||||||
NPI: | 1679534200 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CRANE | ||||||||
FirstName: | CHRISTY | ||||||||
MiddleName: | M | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LUCHS | ||||||||
OtherFirstName: | CHRISTY | ||||||||
OtherMiddleName: | M | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5401 OLD COURT RD | ||||||||
Address2: | ATTN: CREDENTIALING | ||||||||
City: | RANDALLSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 211335103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4106015524 | ||||||||
FaxNumber: | 4106018946 | ||||||||
Practice Location | |||||||||
Address1: | 5401 OLD COURT RD | ||||||||
Address2: |   | ||||||||
City: | RANDALLSTOWN | ||||||||
State: | MD | ||||||||
PostalCode: | 211335103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4105212200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 11/29/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | C0001949 | MD | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | P00337315 | 01 | MD | R/R MEDICARE PROVIDER # | OTHER | CN6601 | 01 | MD | R/R MEDICARE GROUP # | OTHER |