Provider Demographics
NPI:1750471595
Name:CRANICK, TARAH ELISSA (PA)
Entity Type:Individual
Prefix:
First Name:TARAH
Middle Name:ELISSA
Last Name:CRANICK
Suffix:
Gender:F
Credentials:PA
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 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:
Practice Address - Street 1:405 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-1462
Practice Address - Country:US
Practice Address - Phone:618-549-0721
Practice Address - Fax:618-457-0469
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003209363A00000X, 363A00000X
FLPA9103907363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3932056OtherBLUE SHIELD
IL214881Medicare Oscar/Certification
IL3932056OtherBLUE SHIELD
P00396469Medicare PIN
IL213567001Medicare PIN
IL214881040Medicare PIN
FLAC485ZMedicare PIN