Provider Demographics
NPI:1467768804
Name:CRADDOCK, RICHARD W (PA-C)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:W
Last Name:CRADDOCK
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 1:500 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1474
Mailing Address - Country:US
Mailing Address - Phone:304-342-3891
Mailing Address - Fax:304-342-5307
Practice Address - Street 1:500 POPLAR ST
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1474
Practice Address - Country:US
Practice Address - Phone:304-342-3891
Practice Address - Fax:304-342-5307
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVPA22542Medicare PIN