Provider Demographics
NPI:1003225392
Name:DISS, CRAIG (PTA)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:DISS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 CREEPING PHLOX CV
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-8942
Mailing Address - Country:US
Mailing Address - Phone:260-450-4828
Mailing Address - Fax:
Practice Address - Street 1:2625 CREEPING PHLOX CV
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-8942
Practice Address - Country:US
Practice Address - Phone:260-450-4828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06004292A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant