Provider Demographics
NPI:1336399724
Name:CROUSS, CARY LEE
Entity Type:Individual
Prefix:
First Name:CARY
Middle Name:LEE
Last Name:CROUSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 POINT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-5008
Mailing Address - Country:US
Mailing Address - Phone:530-409-4370
Mailing Address - Fax:
Practice Address - Street 1:838 BEACH CT.
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:CA
Practice Address - Zip Code:95613
Practice Address - Country:US
Practice Address - Phone:530-626-7252
Practice Address - Fax:530-626-7934
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9009174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA9009OtherCAARR