Provider Demographics
NPI:1275657462
Name:CROUCH, PAUL ALAN (OTR)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:ALAN
Last Name:CROUCH
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:788 FOXLEY RD
Mailing Address - Street 2:
Mailing Address - City:HOOD RIVER
Mailing Address - State:OR
Mailing Address - Zip Code:97031-9722
Mailing Address - Country:US
Mailing Address - Phone:541-806-0047
Mailing Address - Fax:541-386-3868
Practice Address - Street 1:788 FOXLEY RD
Practice Address - Street 2:
Practice Address - City:HOOD RIVER
Practice Address - State:OR
Practice Address - Zip Code:97031-9722
Practice Address - Country:US
Practice Address - Phone:541-806-0047
Practice Address - Fax:541-386-3868
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1021091174400000X
WAOT00002839174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023087Medicaid
WA7683501Medicaid
OR337703OtherPROVIDENCE HEALTH NUMBER
OR71981OtherHEALTHSCAPE PROVIDER NUM
OR840393000OtherBCBS PROVIDER NUMBER
OR71981OtherHEALTHSCAPE PROVIDER NUM