Provider Demographics
NPI:1154528503
Name:MCCRAE, JOHN (PT)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:
Last Name:MCCRAE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16601 N.12TH ST
Mailing Address - Street 2:APT 2101
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85022
Mailing Address - Country:US
Mailing Address - Phone:602-509-0016
Mailing Address - Fax:
Practice Address - Street 1:16601 N.12TH ST
Practice Address - Street 2:APT 2101
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022
Practice Address - Country:US
Practice Address - Phone:602-509-0016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ7175171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor