Provider Demographics
NPI:1255347530
Name:CROCKER, LEE C (PA)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:C
Last Name:CROCKER
Suffix:
Gender:M
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-421-4489
Practice Address - Street 1:1807 W SLAUGHTER LN #490
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-6208
Practice Address - Country:US
Practice Address - Phone:512-282-8967
Practice Address - Fax:512-292-5143
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00233363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183275002Medicaid
TX183275001Medicaid
TX83N933Medicare PIN
TX183275001Medicaid