Provider Demographics
NPI:1699718403
Name:CROCKETT, MICHAEL G (MPT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:CROCKETT
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2921 S FRONTAGE RD
Mailing Address - Street 2:STE 7
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-2571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2921 S FRONTAGE RD STE 2
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-2571
Practice Address - Country:US
Practice Address - Phone:218-233-7029
Practice Address - Fax:218-233-7029
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1289225100000X
MN6271225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND25396Medicare PIN