Provider Demographics
NPI:1760412605
Name:ENSIGN, CRAIG A (MS-PAC)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:A
Last Name:ENSIGN
Suffix:
Gender:M
Credentials:MS-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 N 300 W STE 316
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3373
Mailing Address - Country:US
Mailing Address - Phone:801-357-7530
Mailing Address - Fax:801-357-7566
Practice Address - Street 1:1055 N 300 W STE 316
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3373
Practice Address - Country:US
Practice Address - Phone:801-357-7530
Practice Address - Fax:801-357-7566
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT293156-8906363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT96-293156-1206OtherPHYS ASSISTANT LIC #