Healthcare Provider Details

I. General information

NPI: 1629199492
Provider Name (Legal Business Name): ROBERT DAVID CRANDALL M.P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BOB CRANDALL

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6340 BARNES RD
COLORADO SPRINGS CO
80922-2602
US

IV. Provider business mailing address

PO BOX 35380
LAS VEGAS NV
89133-5380
US

V. Phone/Fax

Practice location:
  • Phone: 719-522-1133
  • Fax: 719-570-0601
Mailing address:
  • Phone: 702-579-3203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0003720
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: