Healthcare Provider Details

I. General information

NPI: 1427303478
Provider Name (Legal Business Name): CHRISTIAN T CRAWFORD PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2012
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 N HAPPY VALLEY RD
NAMPA ID
83687-5280
US

IV. Provider business mailing address

PO BOX 191050
BOISE ID
83719-1050
US

V. Phone/Fax

Practice location:
  • Phone: 208-809-2869
  • Fax: 208-809-2870
Mailing address:
  • Phone: 208-955-6522
  • Fax: 208-955-6503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1361
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1181
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: