Basic Information
| Provider Information | |||||||||
| NPI: | 1154574689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROUCH | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | CARSON | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 116510 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303686073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123556615 | ||||||||
| FaxNumber: | 9123510645 | ||||||||
| Practice Location | |||||||||
| Address1: | 4425 PAULSEN ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314053662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123556615 | ||||||||
| FaxNumber: | 9123510645 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2008 | ||||||||
| LastUpdateDate: | 04/20/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5623 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 003114220B | 05 | GA | MEDICAID | P00727253 | 01 | SC | RAILROAD MEDICARE ID-RSFPN | OTHER |