Provider Demographics
NPI:1760923494
Name:CRAIG, ETHAN (PA)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:CRAIG
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 VISTA DR STE 3
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:PA
Mailing Address - Zip Code:17268-2541
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 W WOOLBRIGHT RD STE 201
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6398
Practice Address - Country:US
Practice Address - Phone:561-737-8584
Practice Address - Fax:561-737-5703
Is Sole Proprietor?:No
Enumeration Date:2017-03-14
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL9115765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant