| Crossroads Medical Management Pc | |
|
2508 N Harrison Shawnee OK 74804 | |
| (405) 585-2030 | |
| (405) 585-0318 |
| Full Name | Crossroads Medical Management Pc |
|---|---|
| Speciality | Family Medicine |
| Location | 2508 N Harrison, Shawnee, Oklahoma |
| Authorized Official Name and Position | Keith Conaway (OWNER) |
| Authorized Official Contact | 4055852030 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Crossroads Medical Management Pc 2508 N Harrison Shawnee OK 74804 Ph: (405) 585-2030 | Crossroads Medical Management Pc 2508 N Harrison Shawnee OK 74804 Ph: (405) 585-2030 |
| NPI Number | 1780011874 |
|---|---|
| Provider Enumeration Date | 10/03/2013 |
| Last Update Date | 10/16/2018 |
| Medicare PECOS PAC ID | 4183856784 |
|---|---|
| Medicare Enrollment ID | O20140414001788 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1780011874 | NPI | - | NPPES |
| 100131940B | Medicaid | OK |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 19091 (* (Not Available)) | Primary |
| Provider Name | Keith Conaway |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1528035284 PECOS PAC ID: 5890688238 Enrollment ID: I20070927000114 |
| Provider Name | Lacey K Mccrary |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1669769477 PECOS PAC ID: 0446421234 Enrollment ID: I20110928000302 |
| Provider Name | Alicia Chanski |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1801347968 PECOS PAC ID: 4284918640 Enrollment ID: I20170302000619 |
| Provider Name | Cindy Cheatwood |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1144765611 PECOS PAC ID: 4284636762 Enrollment ID: I20171206002597 |
| Provider Name | Dustin James Wade |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1013323336 PECOS PAC ID: 2668718891 Enrollment ID: I20190109002012 |
| Provider Name | Dana Gayle Hanebutt |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1336612662 PECOS PAC ID: 2769722420 Enrollment ID: I20190318000695 |
| Provider Name | Chrissy M Lehew |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1184274052 PECOS PAC ID: 9032530241 Enrollment ID: I20200526001656 |
| Provider Name | Cory Young |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1326664772 PECOS PAC ID: 8325465297 Enrollment ID: I20200825000190 |
| Provider Name | Angela Renee Gunn |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1508479304 PECOS PAC ID: 0446669949 Enrollment ID: I20210513002182 |
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