Provider Demographics
NPI:1720043219
Name:CRUISE, GROVER SCOTT (CRNA)
Entity Type:Individual
Prefix:MR
First Name:GROVER
Middle Name:SCOTT
Last Name:CRUISE
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:PO BOX 2295
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28802-2295
Mailing Address - Country:US
Mailing Address - Phone:828-398-5244
Mailing Address - Fax:828-360-3080
Practice Address - Street 1:125 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-6106
Practice Address - Country:US
Practice Address - Phone:601-310-4509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR847413367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00121803Medicaid
LA2116461Medicaid
LA3B827Medicare PIN
LA2116461Medicaid