Provider Demographics
NPI:1063052561
Name:CRAWFORD, DONALD RUSSEL IV
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:RUSSEL
Last Name:CRAWFORD
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 LAKE PARK BLVD N STE 102
Mailing Address - Street 2:
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-3906
Mailing Address - Country:US
Mailing Address - Phone:910-399-8666
Mailing Address - Fax:
Practice Address - Street 1:1328 LAKE PARK BLVD N STE 102
Practice Address - Street 2:
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428-3906
Practice Address - Country:US
Practice Address - Phone:910-399-8666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012657363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily