Provider Demographics
NPI:1326720475
Name:CROCKER, NIKOLAS
Entity Type:Individual
Prefix:
First Name:NIKOLAS
Middle Name:
Last Name:CROCKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11401 SW 49TH PL
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33330-2806
Mailing Address - Country:US
Mailing Address - Phone:786-356-5035
Mailing Address - Fax:
Practice Address - Street 1:11401 SW 49TH PL
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33330-2806
Practice Address - Country:US
Practice Address - Phone:786-356-5035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11027933363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care