Provider Demographics
NPI:1720021330
Name:ROUSE, CRAIG
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:ROUSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9321 MILBURN LOOP SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98513-3420
Mailing Address - Country:US
Mailing Address - Phone:360-790-1669
Mailing Address - Fax:
Practice Address - Street 1:8160 FREEDOM LN NE
Practice Address - Street 2:SUITE D
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-4753
Practice Address - Country:US
Practice Address - Phone:360-455-4425
Practice Address - Fax:360-455-3200
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00003743152W00000X
AK226152W00000X
WAMR0424806152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK202160317OtherTRICARE PIN #
4536ROOtherREGENCE BLUE SHIELD PIN
WA721551995OtherTRICARE PIN #
410048942OtherRAILROAD MEDICARE PIN #
7283193OtherAETNA PPO PROVIDER #
AKOD2260Medicaid
WAP00327511OtherMEDICARE RAILROAD CARRIER GROUP # DE9528
3183314OtherAETNA HMO PROVIDER #
AKK160164Medicare PIN
WAG8857649Medicare PIN
WA721551995OtherTRICARE PIN #
7283193OtherAETNA PPO PROVIDER #
AK202160317OtherTRICARE PIN #