Provider Demographics
NPI:1174275192
Name:CRAIN, CONNOR WILMAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:WILMAN
Last Name:CRAIN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 LAKE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:TRUSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35173-3879
Mailing Address - Country:US
Mailing Address - Phone:985-750-9713
Mailing Address - Fax:
Practice Address - Street 1:UAB HOSPITAL CICU NORTH PAVILLION
Practice Address - Street 2:619 19TH STREET SOUTH
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233
Practice Address - Country:US
Practice Address - Phone:205-934-4206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-20
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant