Healthcare Provider Details

I. General information

NPI: 1497024335
Provider Name (Legal Business Name): MR. SAMUEL CRANDELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2241 W 16TH ST
SAFFORD AZ
85546-4085
US

IV. Provider business mailing address

4881 E GRANT RD
TUCSON AZ
85712-2704
US

V. Phone/Fax

Practice location:
  • Phone: 520-829-6900
  • Fax: 520-795-9953
Mailing address:
  • Phone: 520-829-6776
  • Fax: 520-829-6661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5000
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: