Provider Demographics
NPI:1144281072
Name:CROCKER, NANCY (MD)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:CROCKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 FULTON AVE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603
Mailing Address - Country:US
Mailing Address - Phone:845-452-1700
Mailing Address - Fax:845-452-1752
Practice Address - Street 1:71 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-1233
Practice Address - Country:US
Practice Address - Phone:603-536-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164576208000000X
NHLT-3687208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01041890Medicaid