Provider Demographics
NPI:1649227307
Name:CROW, IAN J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:IAN
Middle Name:J
Last Name:CROW
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 1:3521A CANNON DR
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-9470
Mailing Address - Country:US
Mailing Address - Phone:530-339-2347
Mailing Address - Fax:
Practice Address - Street 1:3521A CANNON DR
Practice Address - Street 2:
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-9470
Practice Address - Country:US
Practice Address - Phone:530-339-2347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman