Provider Demographics
NPI:1972659902
Name:CROCKER, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:CROCKER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10570 15TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98177-5312
Mailing Address - Country:US
Mailing Address - Phone:509-241-7349
Mailing Address - Fax:509-241-7628
Practice Address - Street 1:9800 4TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2152
Practice Address - Country:US
Practice Address - Phone:206-302-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00018613207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8440604Medicaid
WA232736OtherL&I
WA8440604Medicaid
WA232736OtherL&I
WAE99661Medicare UPIN