Provider Demographics
NPI:1538115951
Name:CROSSNOE, CHETLEN
Entity Type:Individual
Prefix:DR
First Name:CHETLEN
Middle Name:
Last Name:CROSSNOE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4515 MARSHA SHARP FWY
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79407-2520
Mailing Address - Country:US
Mailing Address - Phone:806-744-7223
Mailing Address - Fax:806-740-3325
Practice Address - Street 1:4515 MARSHA SHARP FWY
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79407-2520
Practice Address - Country:US
Practice Address - Phone:806-744-7223
Practice Address - Fax:806-740-3325
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0696207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175472304Medicaid
TX148450101OtherTEAM CHOICE CORE (GRACE CLINIC)
TX148450101OtherFIRSTCARE (GRACE CLINIC)
TX7495745OtherAETNA
TX8V8692OtherBCBS (GRACE CLINIC)
TX7495745OtherAETNA
TX8F3393Medicare PIN
TXI31015Medicare UPIN
TX8D5214Medicare ID - Type Unspecified