Provider Demographics
NPI:1952441305
Name:CROCKETT, KELLEE J (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLEE
Middle Name:J
Last Name:CROCKETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1032 S BRIDGE WAY PL
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6099
Mailing Address - Country:US
Mailing Address - Phone:208-246-0123
Mailing Address - Fax:208-246-0125
Practice Address - Street 1:1032 S BRIDGWAY PL
Practice Address - Street 2:SUITE 100
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616
Practice Address - Country:US
Practice Address - Phone:208-246-0123
Practice Address - Fax:208-246-0125
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPAC636363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant