Provider Demographics
NPI:1972686087
Name:KRALL, DARRELL EDWIN (PT)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:EDWIN
Last Name:KRALL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2180 W IRONWOOD CENTER DR
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2639
Mailing Address - Country:US
Mailing Address - Phone:208-625-3680
Mailing Address - Fax:208-625-3681
Practice Address - Street 1:2180 W IRONWOOD CENTER DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2639
Practice Address - Country:US
Practice Address - Phone:208-625-3680
Practice Address - Fax:208-625-3681
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2024-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00005703225100000X
IDPT-4682251H1200X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1972686087Medicaid
ID807271400Medicaid
ID6215700001Medicare NSC
ID16551601Medicare PIN