Provider Demographics
NPI:1497024335
Name:CRANDELL, SAMUEL
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:CRANDELL
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 1:4881 E GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2704
Mailing Address - Country:US
Mailing Address - Phone:520-829-6776
Mailing Address - Fax:520-829-6661
Practice Address - Street 1:2241 W 16TH ST
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4085
Practice Address - Country:US
Practice Address - Phone:520-829-6900
Practice Address - Fax:520-795-9953
Is Sole Proprietor?:No
Enumeration Date:2011-12-21
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5000363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ312708Medicaid