Provider Demographics
NPI:1962051797
Name:CROCKETT, COURTNIE LYN (PA-C)
Entity type:Individual
Prefix:
First Name:COURTNIE
Middle Name:LYN
Last Name:CROCKETT
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 1:10801 N 32ND ST APT 224
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6780 W THUNDERBIRD RD STE A101
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-5049
Practice Address - Country:US
Practice Address - Phone:028-431-9916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7578363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant