Provider Demographics
NPI:1043865728
Name:CROCK, CAMERON (PA-C)
Entity Type:Individual
Prefix:
First Name:CAMERON
Middle Name:
Last Name:CROCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 508
Mailing Address - Street 2:
Mailing Address - City:NICHOLSON
Mailing Address - State:PA
Mailing Address - Zip Code:18446-0508
Mailing Address - Country:US
Mailing Address - Phone:570-903-0923
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-305-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023825208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery