Provider Demographics
NPI:1093166738
Name:CRAFT, CAROLYN LOUISE-HANRAHAN (PA)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:LOUISE-HANRAHAN
Last Name:CRAFT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9755 W YODER RD
Mailing Address - Street 2:
Mailing Address - City:YODER
Mailing Address - State:IN
Mailing Address - Zip Code:46798-9780
Mailing Address - Country:US
Mailing Address - Phone:317-441-4249
Mailing Address - Fax:
Practice Address - Street 1:7601 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4133
Practice Address - Country:US
Practice Address - Phone:260-436-8686
Practice Address - Fax:260-436-8585
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002089A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN260690085Medicare PIN