Provider Demographics
NPI:1215964614
Name:CRANDELL, BLAIN A (MD)
Entity type:Individual
Prefix:
First Name:BLAIN
Middle Name:A
Last Name:CRANDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 BJUNE DR SE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-2459
Mailing Address - Country:US
Mailing Address - Phone:206-842-3222
Mailing Address - Fax:206-842-1877
Practice Address - Street 1:123 BJUNE DR SE
Practice Address - Street 2:SUITE 101
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2459
Practice Address - Country:US
Practice Address - Phone:206-842-3222
Practice Address - Fax:206-842-1877
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00974408OtherRAILROAD MEDICARE
WA0186660OtherLABOR & INDUSTRIES
WA0284290OtherDEPT OF LABOR AND INDUSTRIES
WA8399065Medicaid
WA8805001Medicare ID - Type Unspecified
WA8399065Medicaid
G8876736Medicare PIN
G8876738Medicare PIN
WA0186660OtherLABOR & INDUSTRIES