Basic Information
| Provider Information | |||||||||
| NPI: | 1982998225 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRUSON | ||||||||
| FirstName: | CHANCE | ||||||||
| MiddleName: | NOLAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 518 | ||||||||
| Address2: | |||||||||
| City: | ARDMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 734020518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794529416 | ||||||||
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| Practice Location | |||||||||
| Address1: | 920 SL YOUNG BLVD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052715635 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2011 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 28615 | OK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.