Provider Demographics
NPI:1881384519
Name:CROCKER, BROOKE ELLISON (PA)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELLISON
Last Name:CROCKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ASHLEY
Other - Last Name:ELLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-7025
Practice Address - Fax:864-560-7388
Is Sole Proprietor?:No
Enumeration Date:2023-05-08
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCQ4529068OtherMEDICARE PIN
SC6503PAMedicaid
SCSCQ4528510OtherMEDICARE PIN