Provider Demographics
NPI:1437243938
Name:CROUCH, RENITA L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:RENITA
Middle Name:L
Last Name:CROUCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:606-330-7835
Mailing Address - Fax:
Practice Address - Street 1:227 FALCON DR # 101
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9792
Practice Address - Country:US
Practice Address - Phone:859-497-5135
Practice Address - Fax:859-497-5140
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA096363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002556Medicaid
KY37903705OtherMEDICAID LAB GROUP
KY4000501OtherMEDICARE LAB GROUP
GA970025767OtherRR MEDICARE PIN
GACB5773OtherRR MEDICARE GROUP
KY0624450Medicare ID - Type Unspecified