Healthcare Provider Details

I. General information

NPI: 1063859643
Provider Name (Legal Business Name): JONATHAN CROPP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2013
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 HIGH ST
SHOALS IN
47581-5501
US

IV. Provider business mailing address

PO BOX 1028
JASPER IN
47547-1028
US

V. Phone/Fax

Practice location:
  • Phone: 812-247-2733
  • Fax: 812-247-2373
Mailing address:
  • Phone: 812-996-8476
  • Fax: 812-996-8497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71004548A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: