Provider Demographics
NPI:1386426922
Name:CRUZAN, ANNELYSE
Entity type:Individual
Prefix:
First Name:ANNELYSE
Middle Name:
Last Name:CRUZAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E BROWN ST STE 302
Mailing Address - Street 2:
Mailing Address - City:EAST STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18301-3013
Mailing Address - Country:US
Mailing Address - Phone:272-212-4000
Mailing Address - Fax:866-230-6623
Practice Address - Street 1:235 E BROWN ST STE 302
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3013
Practice Address - Country:US
Practice Address - Phone:272-212-4000
Practice Address - Fax:866-230-6623
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064921363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant