Doctor Name: | MR. KENNETH ADAMS CROCKETT |
NPI Number: | 1053338830 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | PA-C |
License Number: | 5601001028 |
Business Practice Address: | 1890 S Us Highway 131 Suite 4 Petoskey, MI - 497708344 |
Business Phone Number: | 2314872000 |
Business Fax Number: | |
Mailing Address: | 1890 S Us Highway 131, Suite 4 PETOSKEY |
State: | MI |
Postal Code: | 497708344 |
Phone Number: | 2314872000 |
Fax Number: | |
NPI Enumeration Date: | 07/16/2006 |
NPI Last Update Date: | 04/18/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363AM0700X |
License Number: | 5601001028 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MI |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Physician Assistant |
Taxonomy Specialization: | Medical |
Taxonomy Definition: |