Basic Information
| Provider Information | |||||||||
| NPI: | 1992735815 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUSSER | ||||||||
| FirstName: | KRYSTAL | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BRAGG | ||||||||
| OtherFirstName: | KRYSTAL | ||||||||
| OtherMiddleName: | P | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2817 REILLY ST | ||||||||
| Address2: | WOMACK ARMY MEDICAL CENTER | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078922 | ||||||||
| FaxNumber: | 9109076069 | ||||||||
| Practice Location | |||||||||
| Address1: | 2817 REILLY ST | ||||||||
| Address2: | WOMACK ARMY MEDICAL CENTER | ||||||||
| City: | FORT BRAGG | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283107324 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109078922 | ||||||||
| FaxNumber: | 9109076069 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 02/17/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT001348 | GA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 000606537H | 01 | GA | MEDICAID - RINCON | OTHER | 1992735815 | 01 | GA | MEDICARE RAILROAD | OTHER | 000606537F | 05 | GA | MEDICAID | 000606537G | 01 | GA | MEDICAID- BORO | OTHER | 111065 | 01 | GA | NATL VISION ADMIN | OTHER | 732348 | 01 | GA | BCBS | OTHER | 000606537D | 05 | GA | MEDICAID | 000606537A | 05 | GA | MEDICAID | 000606537E | 05 | GA | MEDICAID | 08525 | 01 | GA | SPECTERA | OTHER | 52484359 | 01 | GA | STATE HEALTH PLAN | OTHER | P00013749 | 01 | GA | RAILROAD MEDICARE | OTHER | 511G701032 | 01 | GA | GA MEDICARE GROUP | OTHER |