Healthcare Provider Details

I. General information

NPI: 1861699621
Provider Name (Legal Business Name): CRAIG CHASE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 06/10/2022
Certification Date: 06/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18710 AMAR RD STE A
WALNUT CA
91789-4571
US

IV. Provider business mailing address

2028 E EDGECOMB ST
COVINA CA
91724-2203
US

V. Phone/Fax

Practice location:
  • Phone: 626-522-6553
  • Fax: 844-400-1763
Mailing address:
  • Phone: 626-965-2334
  • Fax: 626-964-6504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13105
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: