Healthcare Provider Details

I. General information

NPI: 1104762012
Provider Name (Legal Business Name): EVERETT JAMES CROCKETT PHAI.IR.61593108
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 E SPOKANE FALLS BLVD
SPOKANE WA
99202
US

IV. Provider business mailing address

205 E SPOKANE FALLS BLVD
SPOKANE WA
99202
US

V. Phone/Fax

Practice location:
  • Phone: 509-368-6700
  • Fax:
Mailing address:
  • Phone: 509-368-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPHAI.IR.61593108
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: