MEDICARE: MR. MICHAEL LEE CROWELL PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	0769	WY
2	225200000X	Physical Therapy Assistant	2085053	TX

General Provider Information

NPI Number	:	1821423658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL LEE CROWELL PTA

Provider Business Mailing Address
First Line	:	227 RUSSELL BLVD
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1238
Country	:	US
Telephone Number	:	828-360-4294
Fax Number	:

Provider Business Practice Location Address
First Line	:	227 RUSSELL BLVD
Second Line	:
City	:	NACOGDOCHES
State	:	TX
Zip	:	75965-1238
Country	:	US
Telephone Number	:	828-360-4294
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2013
Last Update Date	:	09/11/2013

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