Provider Demographics
NPI:1477021020
Name:CRANOR, TODD (PA-C)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:
Last Name:CRANOR
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 1:3385 POTOMAC WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4978
Mailing Address - Country:US
Mailing Address - Phone:208-522-7246
Mailing Address - Fax:208-529-2620
Practice Address - Street 1:1950 E CLARK ST STE 110
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3315
Practice Address - Country:US
Practice Address - Phone:208-232-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-12
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1650363A00000X
CAPA56759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant