Provider Demographics
NPI:1578512851
Name:SPONSELLER, CRAIG EUGENE (PA-C)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:EUGENE
Last Name:SPONSELLER
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 1:3235 E MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-3971
Mailing Address - Country:US
Mailing Address - Phone:517-787-3280
Mailing Address - Fax:517-787-9680
Practice Address - Street 1:3235 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-3971
Practice Address - Country:US
Practice Address - Phone:517-787-3280
Practice Address - Fax:517-787-9680
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001243363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S07702Medicare UPIN
MIP02040003Medicare ID - Type Unspecified