Provider Demographics
NPI:1720310790
Name:MATSUMOTO, CRAIG ISAO (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:ISAO
Last Name:MATSUMOTO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:1 STAFFORD PL
Mailing Address - Street 2:
Mailing Address - City:SEWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:08080-2548
Mailing Address - Country:US
Mailing Address - Phone:856-228-2114
Mailing Address - Fax:610-328-2023
Practice Address - Street 1:900 OLD MARPLE RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-1211
Practice Address - Country:US
Practice Address - Phone:610-328-1166
Practice Address - Fax:610-328-2023
Is Sole Proprietor?:No
Enumeration Date:2010-02-02
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA0002698-L363A00000X
NJ25MP00086700363A00000X
NY009075-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant