=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598504615
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRUSHNA MANTRI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2024
-----------------------------------------------------
Last Update Date | 03/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2755 SILVER CREEK RD STE 217
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86442-8361
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-704-6070
-----------------------------------------------------
Fax | 928-704-4736
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 689022
-----------------------------------------------------
City | FRANKLIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37068-9022
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-465-7211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------