Healthcare Provider Details

I. General information

NPI: 1528087251
Provider Name (Legal Business Name): GARY CRANDELL P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 HOPE DR
BAGDAD AZ
86321
US

IV. Provider business mailing address

PO BOX 1169 1891 BIGLER LANE
HEBER AZ
85928-1169
US

V. Phone/Fax

Practice location:
  • Phone: 928-633-4111
  • Fax:
Mailing address:
  • Phone: 928-633-5922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2203
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: