Provider Demographics
NPI:1770672925
Name:CRENSHAW, ROBERT EVAN
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EVAN
Last Name:CRENSHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 BICENTENNIAL WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2149
Mailing Address - Country:US
Mailing Address - Phone:707-393-5580
Mailing Address - Fax:707-393-4559
Practice Address - Street 1:401 BICENTENNIAL WAY STE 120
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-393-5580
Practice Address - Fax:707-393-4559
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16184363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ49226Medicare UPIN