Provider Demographics
NPI:1518162379
Name:CRAGUN, KERRINA L (RPT)
Entity Type:Individual
Prefix:MRS
First Name:KERRINA
Middle Name:L
Last Name:CRAGUN
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 801931
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91380-1931
Mailing Address - Country:US
Mailing Address - Phone:661-600-3997
Mailing Address - Fax:661-222-7681
Practice Address - Street 1:1821 WILSHIRE BLVD
Practice Address - Street 2:SUITE 570
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5618
Practice Address - Country:US
Practice Address - Phone:661-600-3997
Practice Address - Fax:661-222-7681
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22518208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT22518Medicare PIN
CA0PT225180Medicare UPIN