Provider Demographics
NPI:1528087251
Name:CRANDELL, GARY (PA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:CRANDELL
Suffix:
Gender:M
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:PO BOX 1169
Mailing Address - Street 2:1891 BIGLER LANE
Mailing Address - City:HEBER
Mailing Address - State:AZ
Mailing Address - Zip Code:85928-1169
Mailing Address - Country:US
Mailing Address - Phone:928-633-5922
Mailing Address - Fax:
Practice Address - Street 1:12 HOPE DR
Practice Address - Street 2:
Practice Address - City:BAGDAD
Practice Address - State:AZ
Practice Address - Zip Code:86321
Practice Address - Country:US
Practice Address - Phone:928-633-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ567753Medicaid
AZ567753Medicaid