Provider Demographics
NPI:1609565332
Name:CROCKER, AUSTIN TAYLOR (PA-S)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:TAYLOR
Last Name:CROCKER
Suffix:
Gender:M
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6434 W RALPH H CIR
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-6732
Mailing Address - Country:US
Mailing Address - Phone:360-449-2578
Mailing Address - Fax:
Practice Address - Street 1:1800 NOVELL PL
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-6101
Practice Address - Country:US
Practice Address - Phone:801-375-5125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program