Healthcare Provider Details

I. General information

NPI: 1760419881
Provider Name (Legal Business Name): TIMOTHY KENT CRAGUN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 11/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 LAS VEGAS BLVD N
NELLIS AFB NV
89191-6600
US

IV. Provider business mailing address

2327 WINDING VW
SAN ANTONIO TX
78260-7263
US

V. Phone/Fax

Practice location:
  • Phone: 702-348-3245
  • Fax:
Mailing address:
  • Phone: 702-582-4830
  • Fax: 210-615-6793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number01054132A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberH0063845
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01054132A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberH0063845
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberDO1722
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: