Provider Demographics
NPI:1871188441
Name:CROCKER, JOVAN ANTWUANE (CRNP)
Entity Type:Individual
Prefix:MR
First Name:JOVAN
Middle Name:ANTWUANE
Last Name:CROCKER
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3623 WABASH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-7435
Mailing Address - Country:US
Mailing Address - Phone:410-262-1063
Mailing Address - Fax:
Practice Address - Street 1:3623 WABASH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-7435
Practice Address - Country:US
Practice Address - Phone:410-262-1063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR187195363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care