Healthcare Provider Details

I. General information

NPI: 1316616618
Provider Name (Legal Business Name): CRAIG MICHAEL CAPPOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2021
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 GLADES RD STE 4A
BOCA RATON FL
33431-6401
US

IV. Provider business mailing address

4855 W HILLSBORO BLVD STE B2
COCONUT CREEK FL
33073-4356
US

V. Phone/Fax

Practice location:
  • Phone: 561-391-8086
  • Fax:
Mailing address:
  • Phone: 954-418-1683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9114866
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: