Provider Demographics
NPI:1538294400
Name:CROCKER, MICHAEL G (RN)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:CROCKER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:726 NE 174TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-6435
Mailing Address - Country:US
Mailing Address - Phone:503-962-0471
Mailing Address - Fax:
Practice Address - Street 1:2507 CHRISTIE DRIVE
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97034
Practice Address - Country:US
Practice Address - Phone:503-675-2285
Practice Address - Fax:503-697-3416
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200542066RN163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse