Healthcare Provider Details

I. General information

NPI: 1356739080
Provider Name (Legal Business Name): CRAIG CROSSMAN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E 13TH ST
GEORGETOWN TX
78626
US

IV. Provider business mailing address

202 PENNSYLVANIA AVE
LOUISVILLE KY
40206-1540
US

V. Phone/Fax

Practice location:
  • Phone: 512-743-1781
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberA03000
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2050823
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: