Provider Demographics
NPI:1134693617
Name:CRAIG, JESTON WADE
Entity Type:Individual
Prefix:
First Name:JESTON
Middle Name:WADE
Last Name:CRAIG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 S BOUNDARY ST
Mailing Address - Street 2:
Mailing Address - City:BURNET
Mailing Address - State:TX
Mailing Address - Zip Code:78611-3202
Mailing Address - Country:US
Mailing Address - Phone:512-755-6603
Mailing Address - Fax:
Practice Address - Street 1:102 S BOUNDARY ST
Practice Address - Street 2:
Practice Address - City:BURNET
Practice Address - State:TX
Practice Address - Zip Code:78611-3202
Practice Address - Country:US
Practice Address - Phone:512-755-6603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-17
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program