Healthcare Provider Details

I. General information

NPI: 1801986690
Provider Name (Legal Business Name): DEAN CROSGROVE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 N 2ND AVE
SANDPOINT ID
83864-1565
US

IV. Provider business mailing address

PO BOX 421
LIBERTY LAKE WA
99019-0421
US

V. Phone/Fax

Practice location:
  • Phone: 208-263-0450
  • Fax:
Mailing address:
  • Phone: 509-252-1900
  • Fax: 509-227-7070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003596
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: