Provider Demographics
NPI:1982998225
Name:CRUSON, CHANCE NOLAN (MD)
Entity Type:Individual
Prefix:
First Name:CHANCE
Middle Name:NOLAN
Last Name:CRUSON
Suffix:
Gender:M
Credentials:MD
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 518
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0518
Mailing Address - Country:US
Mailing Address - Phone:479-452-9416
Mailing Address - Fax:
Practice Address - Street 1:920 SL YOUNG BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104-5036
Practice Address - Country:US
Practice Address - Phone:405-271-5635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-03
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK286152085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology