Provider Demographics
NPI:1083304737
Name:ANCRUM, ALISHA
Entity Type:Individual
Prefix:
First Name:ALISHA
Middle Name:
Last Name:ANCRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 INDUSTRIAL BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-2206
Mailing Address - Country:US
Mailing Address - Phone:833-268-9722
Mailing Address - Fax:
Practice Address - Street 1:400 INDUSTRIAL BLVD STE 210
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-2206
Practice Address - Country:US
Practice Address - Phone:833-268-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0000000202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner