Provider Demographics
NPI:1407859473
Name:CROAKE, TRICIA (MD)
Entity Type:Individual
Prefix:DR
First Name:TRICIA
Middle Name:
Last Name:CROAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 TURNBERRY WAY
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-8509
Mailing Address - Country:US
Mailing Address - Phone:910-889-8822
Mailing Address - Fax:910-889-8922
Practice Address - Street 1:165 TURNBERRY WAY
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8509
Practice Address - Country:US
Practice Address - Phone:910-889-8822
Practice Address - Fax:910-889-8922
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076834208VP0014X
OH35076834C207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH42799948OtherAETNA
OH76834OtherCHOICE CARE
OH2268988Medicaid
OHCR4057144OtherMEDICARE PTAN
OHCR4057142Medicare ID - Type Unspecified
OHCR4057144OtherMEDICARE PTAN