Basic Information
| Provider Information | |||||||||
| NPI: | 1861686495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENSER | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | CSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44 MCCOY AVE | ||||||||
| Address2: | SUITE 442 | ||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424312867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708246655 | ||||||||
| FaxNumber: | 2708246629 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 MCCOY AVE | ||||||||
| Address2: | SUITE 442 | ||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424312867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708246655 | ||||||||
| FaxNumber: | 2708246629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2007 | ||||||||
| LastUpdateDate: | 08/06/2012 | ||||||||
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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 | 246ZS0410X | SA167 | KY | Y |
ID Information
| ID | Type | State | Issuer | Description | 000000530711 | 01 | KY | ANTHEM PIN # | OTHER | SA167 | 01 | KY | SURGICAL ASSISTANT - KY BD OF MEDICAL LIC # | OTHER | 3031 | 01 | SURGICAL ASSIST ASSOC # | OTHER |