Provider Demographics
NPI:1124591458
Name:CREACHBAUM, MARKUS JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARKUS
Middle Name:JOHN
Last Name:CREACHBAUM
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 1:700 ACKERMAN RD STE 570
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1579
Mailing Address - Country:US
Mailing Address - Phone:614-293-9450
Mailing Address - Fax:614-293-9451
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-685-5695
Practice Address - Fax:614-293-4726
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005851RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0336991Medicaid