Provider Demographics
NPI:1194316612
Name:CROUCH, KAITLYN NICOLE (PA-C)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:NICOLE
Last Name:CROUCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7370 N PALM AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-5782
Mailing Address - Country:US
Mailing Address - Phone:559-228-5400
Mailing Address - Fax:
Practice Address - Street 1:729 N MEDICAL CENTER DR W STE 101
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6880
Practice Address - Country:US
Practice Address - Phone:559-439-7633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant