Provider Demographics
NPI:1285659953
Name:CROOK, TINA M (PA-C)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:CROOK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4170 CEDAR BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-9600
Mailing Address - Country:US
Mailing Address - Phone:231-487-2230
Mailing Address - Fax:231-487-6172
Practice Address - Street 1:4170 CEDAR BLUFF DR.
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770
Practice Address - Country:US
Practice Address - Phone:231-487-2230
Practice Address - Fax:231-487-6172
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004367363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601004367OtherPHSYICIAN ASSISTANT LICEN