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General NPI Number Information
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NPI Number | 1982283800
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Entity Type | Individual
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Provider Name | EVAN CROCKER
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Gender | Male
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Dates
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Enumeration Date | 04/07/2021
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Last Update Date | 04/08/2021
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Provider Practice Location Address
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Address Line | 7455 MORGAN RD
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City | LIVERPOOL
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State | NY
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Zip | 13090-3956
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Country | US
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Telephone | 315-451-6767
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Fax |
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Provider Business Mailing Address
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Address Line | 3580 HORSESHOE ISLAND RD
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City | CLAY
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State | NY
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Zip | 13041-9687
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Country | US
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Telephone | 330-212-6587
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 046192
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License Number State | NY
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