Provider Demographics
NPI:1265809834
Name:MCCRACKEN, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MCCRACKEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 SUNSET DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40342-1462
Mailing Address - Country:US
Mailing Address - Phone:502-680-5066
Mailing Address - Fax:
Practice Address - Street 1:403 SUNSET DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:KY
Practice Address - Zip Code:40342-1462
Practice Address - Country:US
Practice Address - Phone:502-680-5066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-30
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1790731081Medicaid