Provider Demographics
NPI:1073031308
Name:CRAGHEAD, WILSON MERRELL (PA-C)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:MERRELL
Last Name:CRAGHEAD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:WILL
Other - Middle Name:
Other - Last Name:CRAGHEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1327 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-6503
Mailing Address - Country:US
Mailing Address - Phone:480-734-8254
Mailing Address - Fax:
Practice Address - Street 1:459 S GILBERT RD
Practice Address - Street 2:SUITE A-138
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234
Practice Address - Country:US
Practice Address - Phone:623-226-8825
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6837207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine