Provider Demographics
NPI:1275964504
Name:RODRIGUEZ, CRAIG ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:ALLEN
Last Name:RODRIGUEZ
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 1:861 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-1840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:861 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-1840
Practice Address - Country:US
Practice Address - Phone:435-558-7031
Practice Address - Fax:702-576-9609
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1471363AM0700X
UT12256467-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical