Provider Demographics
NPI:1356555148
Name:CRAYTON, RICHARD LEROY
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:LEROY
Last Name:CRAYTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RICK
Other - Middle Name:
Other - Last Name:CRAYTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:2862 W LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-9710
Mailing Address - Country:US
Mailing Address - Phone:573-686-6682
Mailing Address - Fax:
Practice Address - Street 1:2620 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-3396
Practice Address - Country:US
Practice Address - Phone:573-785-7721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO088632367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO140080001Medicare PIN