Provider Demographics
NPI:1669524245
Name:BRAITHWAITE, CRAIG (PA-C)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:
Last Name:BRAITHWAITE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 954
Mailing Address - Street 2:638 WADING RIVER HOLLOW ROAD
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-0954
Mailing Address - Country:US
Mailing Address - Phone:631-924-0624
Mailing Address - Fax:
Practice Address - Street 1:506 MALCOLM X BLVD
Practice Address - Street 2:EMERGENCY DEPT- MLK ROOM 2105H
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-2236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003135-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant