Provider Demographics
NPI:1245570613
Name:CROFT, JORY GIBBONS (PA)
Entity Type:Individual
Prefix:
First Name:JORY
Middle Name:GIBBONS
Last Name:CROFT
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 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-1529
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:803-259-3250
Practice Address - Street 1:AIKEN SPECIALTY SERVICES
Practice Address - Street 2:209 ABBEVILLE AVE NW
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801
Practice Address - Country:US
Practice Address - Phone:803-306-1433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1896363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1896OtherSC MEDICAL BOARD LICENSE NUMBER
SC1646PAMedicaid