1386078137 NPI number — MRS. KATHERINE MARIE CROCKER P.A.-C

Table of content: MRS. KATHERINE MARIE CROCKER P.A.-C (NPI 1386078137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386078137 NPI number — MRS. KATHERINE MARIE CROCKER P.A.-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROCKER
Provider First Name:
KATHERINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386078137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170 MORTON STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JAMAICA PLAIN
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-971-3305
Provider Business Mailing Address Fax Number:
617-971-3643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 MORTON STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMAICA PLAIN
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-971-3305
Provider Business Practice Location Address Fax Number:
617-971-3643
Provider Enumeration Date:
08/29/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA4959 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2025 www.npivalidator.com