Provider Demographics
NPI:1760724306
Name:CROSS, MIKE WAYNE
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:WAYNE
Last Name:CROSS
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 1:7509 NW MORROCCO RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-1221
Mailing Address - Country:US
Mailing Address - Phone:580-647-6370
Mailing Address - Fax:
Practice Address - Street 1:7509 NW MORROCCO RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-1221
Practice Address - Country:US
Practice Address - Phone:580-647-6370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor