Basic Information
| Provider Information | |||||||||
| NPI: | 1811169485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRAGUN | ||||||||
| FirstName: | JANIEL | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 E ELVIRA RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857567124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5208743500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1501 N CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857240001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206946010 | ||||||||
| FaxNumber: | 5206942892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2008 | ||||||||
| LastUpdateDate: | 08/07/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 1234 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 345093 | 05 | AZ | MEDICAID |