Provider Demographics
NPI:1932710118
Name:CAROL L. CROCKER, FNP PC
Entity Type:Organization
Organization Name:CAROL L. CROCKER, FNP PC
Other - Org Name:CAROL CROCKER FNP PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:CROCKER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:541-505-0027
Mailing Address - Street 1:500 MAIN STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477
Mailing Address - Country:US
Mailing Address - Phone:541-505-0027
Mailing Address - Fax:541-505-7468
Practice Address - Street 1:500 MAIN STREET
Practice Address - Street 2:SUITE A
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477
Practice Address - Country:US
Practice Address - Phone:541-505-0027
Practice Address - Fax:541-505-7468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR027960Medicaid