Provider Demographics
NPI:1639667405
Name:TAMBATAMBA, CRAIG M (PA-C)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:M
Last Name:TAMBATAMBA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14780 W MOUNTAIN VIEW BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-7280
Mailing Address - Country:US
Mailing Address - Phone:623-374-7774
Mailing Address - Fax:855-420-6361
Practice Address - Street 1:16064 W WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-3494
Practice Address - Country:US
Practice Address - Phone:623-202-6413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-27
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7071363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant