Provider Demographics
NPI:1942458922
Name:MCCRACKEN, DALLAS JAMES (PA-C)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:JAMES
Last Name:MCCRACKEN
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 1:215 BROOKSHIRE LN
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-6729
Mailing Address - Country:US
Mailing Address - Phone:304-253-1077
Mailing Address - Fax:304-253-9611
Practice Address - Street 1:215 BROOKSHIRE LN
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-6729
Practice Address - Country:US
Practice Address - Phone:304-253-1077
Practice Address - Fax:304-253-9611
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV958363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP68729Medicare UPIN