Provider Demographics
NPI:1093910127
Name:CRONK, DONNA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:CRONK
Suffix:
Gender:F
Credentials:PA
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 130
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-0130
Mailing Address - Country:US
Mailing Address - Phone:970-858-9894
Mailing Address - Fax:970-858-1331
Practice Address - Street 1:281 N PLUM ST
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-2100
Practice Address - Country:US
Practice Address - Phone:970-858-9894
Practice Address - Fax:970-858-1331
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0000342363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07003429Medicaid
CO15424OtherKAISER COMMERCIAL NUMBER
COC801431Medicare PIN
CO07003429Medicaid