Healthcare Provider Details

I. General information

NPI: 1194316612
Provider Name (Legal Business Name): KAITLYN NICOLE CROUCH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 01/27/2021
Certification Date: 01/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 N MEDICAL CENTER DR W STE 101
CLOVIS CA
93611-6880
US

IV. Provider business mailing address

7370 N PALM AVE STE 101
FRESNO CA
93711-5782
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-7633
  • Fax:
Mailing address:
  • Phone: 559-228-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58624
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: