Provider Demographics
NPI:1306220645
Name:CRACRAFT, BRANDON BRYON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:BRYON
Last Name:CRACRAFT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:461 S COLUMBUS BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-4751
Mailing Address - Country:US
Mailing Address - Phone:609-969-2113
Mailing Address - Fax:
Practice Address - Street 1:461 S COLUMBUS BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-4751
Practice Address - Country:US
Practice Address - Phone:609-969-2113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5265491171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor