Provider Demographics
NPI:1447600333
Name:BROCK, CRISSIE ALAYNE (PA- C)
Entity Type:Individual
Prefix:MS
First Name:CRISSIE
Middle Name:ALAYNE
Last Name:BROCK
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 1:930 SE 4TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-3221
Mailing Address - Country:US
Mailing Address - Phone:817-271-7425
Mailing Address - Fax:
Practice Address - Street 1:2800 VILLAGE RD
Practice Address - Street 2:# 108
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-4193
Practice Address - Country:US
Practice Address - Phone:817-573-0444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-21
Last Update Date:2016-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant