Healthcare Provider Details

I. General information

NPI: 1205275286
Provider Name (Legal Business Name): BRANDON WILLIAM CRANDALL NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2013
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 WEST TAFT RD. SUITE 1C
LIVERPOOL NY
13088
US

IV. Provider business mailing address

37 W GARDEN ST STE 105
AUBURN NY
13021-2663
US

V. Phone/Fax

Practice location:
  • Phone: 315-452-2333
  • Fax: 315-452-2336
Mailing address:
  • Phone: 315-252-0000
  • Fax: 315-252-0070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF337995
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: