Provider Demographics
NPI:1356861157
Name:LONESTAR SURGICAL PROFESSIONALS LLC
Entity type:Organization
Organization Name:LONESTAR SURGICAL PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CRYSTALRAE
Authorized Official - Middle Name:CODDINGTON
Authorized Official - Last Name:MCPHERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CSFA
Authorized Official - Phone:602-708-2493
Mailing Address - Street 1:PO BOX 2405
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-7405
Mailing Address - Country:US
Mailing Address - Phone:602-708-2493
Mailing Address - Fax:
Practice Address - Street 1:212 JOYCE ST
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76085-9524
Practice Address - Country:US
Practice Address - Phone:602-708-2493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty