Healthcare Provider Details

I. General information

NPI: 1477518710
Provider Name (Legal Business Name): PATRICK A CRADDOCK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CENTRAL AVE SE
ALBUQUERQUE NM
87106-4930
US

IV. Provider business mailing address

PO BOX 26666 PRESBYTERIAN HEALTHCARE SERVICES
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1125
  • Fax: 505-841-1737
Mailing address:
  • Phone: 505-923-6770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number15623C
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberM1605
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2024034796
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD2013-0163
License Number StateNM
# 5
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberM1605
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: