Provider Demographics
NPI:1275125494
Name:EDSON, CRAIG JON
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:JON
Last Name:EDSON
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 1:249 12TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTHUMBERLAND
Mailing Address - State:PA
Mailing Address - Zip Code:17857-1317
Mailing Address - Country:US
Mailing Address - Phone:570-441-5290
Mailing Address - Fax:
Practice Address - Street 1:541 N FRANKLIN ST STE 1
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-6754
Practice Address - Country:US
Practice Address - Phone:570-644-9801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
000678225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist