Provider Demographics
NPI:1902814544
Name:CRAWFORD, FARA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:FARA
Middle Name:LYNN
Last Name:CRAWFORD
Suffix:
Gender:F
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 1:6600 FISH POND RD STE 101
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2582
Mailing Address - Country:US
Mailing Address - Phone:254-776-3188
Mailing Address - Fax:254-776-3607
Practice Address - Street 1:6600 FISH POND RD STE 101
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-2582
Practice Address - Country:US
Practice Address - Phone:254-776-3188
Practice Address - Fax:254-776-3607
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04837363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX280585501Medicaid
TXPA04837OtherSTATE LICENSE
TX280585502Medicaid
TX280585503Medicaid
TX280585503Medicaid
TX280585502Medicaid
TXTXB125244Medicare PIN