MEDICARE: LOREN ELAINE CRAGLE PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	50.003693	OH
2	363A00000X	Physician Assistant	2589	SC

General Provider Information

NPI Number	:	1538406491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOREN ELAINE CRAGLE PA-C

Provider Business Mailing Address
First Line	:	12 THORNCLIFF CT
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-6578
Country	:	US
Telephone Number	:	570-704-8151
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 THE PKWY STE N
Second Line	:
City	:	GREER
State	:	SC
Zip	:	29650-5205
Country	:	US
Telephone Number	:	864-655-4005
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2013
Last Update Date	:	02/23/2018

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