Healthcare Provider Details

I. General information

NPI: 1285888180
Provider Name (Legal Business Name): COASTAL VASCULAR AND INTERVENTIONAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2008
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5149 N. 9TH AVENUE SUITE 120
PENSACOLA FL
32504-8734
US

IV. Provider business mailing address

P.O. BOX 11982
PENSACOLA FL
32524-1982
US

V. Phone/Fax

Practice location:
  • Phone: 850-479-1805
  • Fax: 850-479-1829
Mailing address:
  • Phone: 850-479-7200
  • Fax: 850-479-1829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. CHRISTOPHER J LECROY
Title or Position: OWNER, PHYSICIAN
Credential: MD
Phone: 850-479-1805