Provider Demographics
NPI:1013071091
Name:CRENSHAW, JERI LATRICE (PA)
Entity type:Individual
Prefix:
First Name:JERI
Middle Name:LATRICE
Last Name:CRENSHAW
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3244 31ST ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11106-2630
Mailing Address - Country:US
Mailing Address - Phone:718-956-6565
Mailing Address - Fax:718-956-7463
Practice Address - Street 1:3244 31ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11106-2630
Practice Address - Country:US
Practice Address - Phone:718-956-6565
Practice Address - Fax:718-956-7463
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009329363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009329OtherLICENSE