Provider Demographics
NPI:1659681096
Name:CRAIG, GLORIA PEREZ (NP)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:PEREZ
Last Name:CRAIG
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3565 DEL AMO BLVD
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503
Mailing Address - Country:US
Mailing Address - Phone:310-214-5723
Mailing Address - Fax:310-793-3756
Practice Address - Street 1:3565 DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1637
Practice Address - Country:US
Practice Address - Phone:310-214-5723
Practice Address - Fax:310-793-3756
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP19875363L00000X
CA375381363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01376455OtherRR MEDICARE
CAEFF: 7/15/14 - WILMMedicaid
CAEFF: 7/15/14Medicaid
CACB219280Medicare PIN
CAEFF: 7/15/14 - WILMMedicaid