Provider Demographics
NPI:1235102229
Name:CRENSHAW, JOHN A (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:CRENSHAW
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4655 MANORLAKE DR
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:OH
Mailing Address - Zip Code:45040-9016
Mailing Address - Country:US
Mailing Address - Phone:513-398-2198
Mailing Address - Fax:
Practice Address - Street 1:4655 MANORLAKE DR
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040-9016
Practice Address - Country:US
Practice Address - Phone:513-398-2198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH02034367500000X
OH170575163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000246656OtherANTHEM BLUE SHIELD
IN200404270Medicaid
728004OtherBUCKEYE
KY74005398Medicaid
OH0966272Medicaid
OH0966272Medicaid
430076886Medicare PIN