MEDICARE: MR. CODY LAWRENCE CRISMAN AGACNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	1030954	TX

General Provider Information

NPI Number	:	1134713555
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CODY LAWRENCE CRISMAN AGACNP-BC

Provider Business Mailing Address
First Line	:	501 BLYTH RD
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77904-2823
Country	:	US
Telephone Number	:	361-208-5781
Fax Number	:

Provider Business Practice Location Address
First Line	:	605 E SAN ANTONIO ST STE 430E
Second Line	:
City	:	VICTORIA
State	:	TX
Zip	:	77901-6007
Country	:	US
Telephone Number	:	361-576-0011
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2021
Last Update Date	:	02/25/2021

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