Basic Information
Provider Information | |||||||||
NPI: | 1720162142 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAURA J MCCRACKIN, MD, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1129 | ||||||||
Address2: |   | ||||||||
City: | DELTA | ||||||||
State: | CO | ||||||||
PostalCode: | 814161129 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708742470 | ||||||||
FaxNumber: | 9708742475 | ||||||||
Practice Location | |||||||||
Address1: | 95 STAFFORD LN | ||||||||
Address2: |   | ||||||||
City: | DELTA | ||||||||
State: | CO | ||||||||
PostalCode: | 814163465 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9708748026 | ||||||||
FaxNumber: | 9708745430 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2006 | ||||||||
LastUpdateDate: | 01/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCRACKIN | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
AuthorizedOfficialTelephone: | 9708748026 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 41108 | CO | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 77683269 | 05 | CO |   | MEDICAID | MC662516 | 01 | CO | BCBS | OTHER |