Provider Demographics
NPI:1619151099
Name:CRAWFORD, JIMMIE CONRAD (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JIMMIE
Middle Name:CONRAD
Last Name:CRAWFORD
Suffix:
Gender:M
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 1:514 PITNEY DR
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062
Mailing Address - Country:US
Mailing Address - Phone:765-646-8439
Mailing Address - Fax:
Practice Address - Street 1:2015 JACKSON ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4337
Practice Address - Country:US
Practice Address - Phone:765-646-8439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-20
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002163A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2930196 00Medicaid
FL2930196 00Medicaid