Basic Information
| Provider Information | |||||||||
| NPI: | 1982809828 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CROWLEY | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 635283 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452635283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593445555 | ||||||||
| FaxNumber: | 8593445552 | ||||||||
| Practice Location | |||||||||
| Address1: | 525 ALEXANDRIA PIKE | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410713290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592120175 | ||||||||
| FaxNumber: | 8594413698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2007 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3004900 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | COA.09136-NP | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100098400 | 05 | KY | MEDICAID |