Provider Demographics
NPI:1700997681
Name:CROUGH, GAYLE M (NP)
Entity Type:Individual
Prefix:
First Name:GAYLE
Middle Name:M
Last Name:CROUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:10058 WOLF ROAD
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95949
Practice Address - Country:US
Practice Address - Phone:530-745-1500
Practice Address - Fax:530-745-1505
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP11157363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN298918Medicaid
CARN298918Medicaid
ZZZ22886ZMedicare ID - Type Unspecified