Provider Demographics
NPI:1225286347
Name:TATOM, CRAIG (APN)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:
Last Name:TATOM
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:MO
Mailing Address - Zip Code:65560-0069
Mailing Address - Country:US
Mailing Address - Phone:573-729-6112
Mailing Address - Fax:573-729-4035
Practice Address - Street 1:HWY 72 N PHYSICIANS OFFICE BUILDING II
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MO
Practice Address - Zip Code:65560
Practice Address - Country:US
Practice Address - Phone:573-729-6112
Practice Address - Fax:573-729-4035
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO128312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO128312OtherSTATE LICENSE
2008004369OtherANCC CERTIFICATION