Provider Demographics
NPI:1245802438
Name:CROWE, NICOLE (PA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CROWE
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 1:4770 REGENT BLVD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-2445
Mailing Address - Country:US
Mailing Address - Phone:972-891-3750
Mailing Address - Fax:972-885-6494
Practice Address - Street 1:1401 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2113
Practice Address - Country:US
Practice Address - Phone:817-250-5698
Practice Address - Fax:817-250-5698
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
25771780OtherASCP