Provider Demographics
NPI:1780971119
Name:CRIM, DEANE NICOLE (PA)
Entity type:Individual
Prefix:
First Name:DEANE
Middle Name:NICOLE
Last Name:CRIM
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 1:1001 US HIGHWAY 83 N
Mailing Address - Street 2:
Mailing Address - City:CHILDRESS
Mailing Address - State:TX
Mailing Address - Zip Code:79201-2322
Mailing Address - Country:US
Mailing Address - Phone:940-937-3636
Mailing Address - Fax:940-937-9554
Practice Address - Street 1:1001 US HIGHWAY 83 N
Practice Address - Street 2:
Practice Address - City:CHILDRESS
Practice Address - State:TX
Practice Address - Zip Code:79201-2322
Practice Address - Country:US
Practice Address - Phone:940-937-3636
Practice Address - Fax:940-937-9554
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX285481201Medicaid
TX285481202Medicaid
TXP01010811OtherRAILROAD
TXTXB165022Medicare PIN