Provider Demographics
NPI:1770143141
Name:CRUISE, PON TI
Entity type:Individual
Prefix:
First Name:PON TI
Middle Name:
Last Name:CRUISE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 DOCTORS LN
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-8515
Mailing Address - Country:US
Mailing Address - Phone:814-226-3494
Mailing Address - Fax:814-226-3478
Practice Address - Street 1:55 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-2302
Practice Address - Country:US
Practice Address - Phone:740-593-5991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT019100207Q00000X
OH34.015970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty