Provider Demographics
NPI:1740394469
Name:CRANDALL, LIZ ALLYSON (MD)
Entity Type:Individual
Prefix:
First Name:LIZ
Middle Name:ALLYSON
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 W 65TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2106
Mailing Address - Country:US
Mailing Address - Phone:952-920-7001
Mailing Address - Fax:952-920-2245
Practice Address - Street 1:3625 W 65TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2106
Practice Address - Country:US
Practice Address - Phone:952-920-7001
Practice Address - Fax:952-920-2245
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN35627207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1M507CROtherBCBS
MN0725457OtherMEDICA
MN994508300Medicaid
MNF30014Medicare UPIN
MN994508300Medicaid