Provider Demographics
NPI:1720048002
Name:CRAWFORD, ALAN GREGORY (PA)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:GREGORY
Last Name:CRAWFORD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 3488
Mailing Address - Street 2:DEPT 05-115
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38803-3488
Mailing Address - Country:US
Mailing Address - Phone:228-872-8873
Mailing Address - Fax:678-553-8152
Practice Address - Street 1:24 MARKS ROAD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564
Practice Address - Country:US
Practice Address - Phone:228-872-8873
Practice Address - Fax:228-872-8876
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-23
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA013207N00000X
MSPA00013363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00126840Medicaid
MS970000023Medicare PIN
MS970000023Medicare ID - Type Unspecified