Healthcare Provider Details

I. General information

NPI: 1992000574
Provider Name (Legal Business Name): PATRICK TYE CREASY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 10/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E WASHINGTON ST SUITE 301
COLTON CA
92324-7111
US

IV. Provider business mailing address

900 E WASHINGTON ST SUITE 301
COLTON CA
92324-7111
US

V. Phone/Fax

Practice location:
  • Phone: 909-370-0300
  • Fax: 909-370-0303
Mailing address:
  • Phone: 909-370-0300
  • Fax: 909-370-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA21414
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA21414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: