Provider Demographics
NPI:1528013166
Name:HUMES, CRAIG S (PA)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:S
Last Name:HUMES
Suffix:
Gender:M
Credentials:PA
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 30180
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84130-0180
Mailing Address - Country:US
Mailing Address - Phone:801-357-7475
Mailing Address - Fax:801-357-7997
Practice Address - Street 1:1100 S MEDICAL DR
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:UT
Practice Address - Zip Code:84647-2222
Practice Address - Country:US
Practice Address - Phone:435-462-2441
Practice Address - Fax:435-462-2609
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1018291206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807932900Medicaid
ID807932900Medicaid
UT$$$$$$$$$OtherBCBS OF UTAH
UTR61219Medicare UPIN