Provider Demographics
NPI:1174524516
Name:CROWDER, DIANA P (PAC)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:P
Last Name:CROWDER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:DIANA
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1755 N MECKLENBURG AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-4080
Practice Address - Country:US
Practice Address - Phone:434-447-3151
Practice Address - Fax:434-584-5023
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001616363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010117852Medicaid
P95850Medicare UPIN
006072351Medicare ID - Type Unspecified