Provider Demographics
NPI:1215609144
Name:MCRAE, DAELUN JACOB (PA-C)
Entity type:Individual
Prefix:
First Name:DAELUN
Middle Name:JACOB
Last Name:MCRAE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:DAELUN
Other - Middle Name:JACOB
Other - Last Name:MCRAE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:888 S GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-4010
Mailing Address - Country:US
Mailing Address - Phone:480-892-1300
Mailing Address - Fax:
Practice Address - Street 1:5564 S KEENE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-2130
Practice Address - Country:US
Practice Address - Phone:928-651-2960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X
AZ8817363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant