Basic Information
| Provider Information | |||||||||
| NPI: | 1376142893 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CROW | ||||||||
| FirstName: | CANDICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 LEANNE LOOP | ||||||||
| Address2: | |||||||||
| City: | BASTROP | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712206104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183685144 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1541 KINGS HWY | ||||||||
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| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034228 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3183307000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2020 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 207014 | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 363LG0600X | 207014 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.