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: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 21ST ST STE R
SACRAMENTO CA
95811-5226
US

IV. Provider business mailing address

1401 21ST ST STE R
SACRAMENTO CA
95811-5226
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-7633
  • Fax: 559-260-1131
Mailing address:
  • Phone: 209-260-1131
  • 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: