Basic Information
| Provider Information | |||||||||
| NPI: | 1497743264 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRONKRIGHT | ||||||||
| FirstName: | HOLLY | ||||||||
| MiddleName: | AYN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SWEARINGEN | ||||||||
| OtherFirstName: | HOLLY | ||||||||
| OtherMiddleName: | AYN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2782 S OTSEGO AVE | ||||||||
| Address2: | |||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497359404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894972500 | ||||||||
| FaxNumber: | 9897326577 | ||||||||
| Practice Location | |||||||||
| Address1: | 2782 S OTSEGO AVE | ||||||||
| Address2: | |||||||||
| City: | GAYLORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497359404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894972500 | ||||||||
| FaxNumber: | 9897326577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601003438 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00214270 | 01 | RAILROAD MEDICARE | OTHER | 010G27604 | 01 | MI | BCBS OF MICHIGAN | OTHER | 1010143 | 01 | MCLAREN HEALTH PLAN | OTHER | 139500 | 01 | GREAT LAKES HEALTH PLAN | OTHER | 253 | 01 | MI | COMMUNITY CHOICE | OTHER | 080G310660 | 01 | MI | BCBS MI | OTHER | 1010143 | 01 | HEALTH ADVANTAGE | OTHER | 3500576 | 01 | MI | MOLINA HEALTH CARE | OTHER |