Provider Demographics
NPI:1801892492
Name:CRAWFORD, KELLY R (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:R
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 DORNACH WAY
Mailing Address - Street 2:
Mailing Address - City:ADVANCE
Mailing Address - State:NC
Mailing Address - Zip Code:27006-7305
Mailing Address - Country:US
Mailing Address - Phone:336-940-2407
Mailing Address - Fax:336-940-2409
Practice Address - Street 1:108 DORNACH WAY
Practice Address - Street 2:
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-7305
Practice Address - Country:US
Practice Address - Phone:336-940-2407
Practice Address - Fax:336-940-2409
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103844363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2759524Medicare ID - Type Unspecified