Basic Information
Provider Information | |||||||||
NPI: | 1346235843 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CROCKER | ||||||||
FirstName: | JULIE | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2331 FRANKLIN RD SW | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240141111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407251226 | ||||||||
FaxNumber: | 5408575306 | ||||||||
Practice Location | |||||||||
Address1: | 2331 FRANKLIN RD SW | ||||||||
Address2: |   | ||||||||
City: | ROANOKE | ||||||||
State: | VA | ||||||||
PostalCode: | 240141111 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5407251226 | ||||||||
FaxNumber: | 5408575306 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2005 | ||||||||
LastUpdateDate: | 08/03/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 0110001036 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
ID | Type | State | Issuer | Description | 1346235843 | 01 | VA | MEDICAID QMB | OTHER | 1346235843 | 01 | VA | UMWA | OTHER | 540506332108 | 01 | VA | TRICARE/CHAMPUS | OTHER | 1346235843 | 01 | VA | HUMANA MEDICARE | OTHER | P00359240 | 01 | VA | RAILROAD MEDICARE | OTHER | 1346235843 | 01 | VA | SOUTHERN HEALTH/CARENET/CARELINK/COVENTRY | OTHER | 1346235843 | 01 | VA | OPTIMA HEALTH PLAN | OTHER | 1346235843 | 01 | VA | ANTHEM MEDIGAP | OTHER | 1346235843 | 01 | VA | INTOTAL | OTHER | 371194700 | 01 | VA | BLACK LUNG | OTHER | 1346235843 | 01 | VA | AETNA | OTHER | 1346235843 | 01 | VA | CCC VIRGINIA PREMIER | OTHER |