Healthcare Provider Details

I. General information

NPI: 1780451492
Provider Name (Legal Business Name): CRAIG DAVID QUEZADA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2023
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2521 SAN DOMINGO ST
CORAL GABLES FL
33134-5560
US

IV. Provider business mailing address

2521 SAN DOMINGO ST
CORAL GABLES FL
33134-5560
US

V. Phone/Fax

Practice location:
  • Phone: 757-750-5458
  • Fax:
Mailing address:
  • Phone: 757-750-5458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.PA.61637735
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9118229
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: