Provider Demographics
NPI:1356422554
Name:POWELL, CRANFORD RICHARD (PA-C)
Entity type:Individual
Prefix:MR
First Name:CRANFORD
Middle Name:RICHARD
Last Name:POWELL
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 1:1155 THICKET CT APT A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-9700
Mailing Address - Country:US
Mailing Address - Phone:812-343-5512
Mailing Address - Fax:317-481-6629
Practice Address - Street 1:2555 KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-5004
Practice Address - Country:US
Practice Address - Phone:317-481-6626
Practice Address - Fax:317-481-6629
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA000033-46363AM0700X
IN10001530A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN10001530AOtherPA
FLPA000033-46OtherPA