Basic Information
Provider Information | |||||||||
NPI: | 1457558512 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KRANTZ | ||||||||
FirstName: | TONYA | ||||||||
MiddleName: | C. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1822 MEMORIAL DR | ||||||||
Address2: |   | ||||||||
City: | CLARKSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 370434605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9315528012 | ||||||||
FaxNumber: | 9315513118 | ||||||||
Practice Location | |||||||||
Address1: | 1822 MEMORIAL DR | ||||||||
Address2: |   | ||||||||
City: | CLARKSVILLE | ||||||||
State: | TN | ||||||||
PostalCode: | 370434605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9315528012 | ||||||||
FaxNumber: | 9315513118 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 000263 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 3728817 | 05 | TN |   | MEDICAID | 4102314 | 01 | TN | BLUE CROSS BLUE SHIELD | OTHER |