Healthcare Provider Details

I. General information

NPI: 1699052357
Provider Name (Legal Business Name): CRAIG STEPHEN KANTACK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S WOODRUFF AVE
IDAHO FALLS ID
83401-5285
US

IV. Provider business mailing address

944 W 97TH S
IDAHO FALLS ID
83402-5842
US

V. Phone/Fax

Practice location:
  • Phone: 208-542-9111
  • Fax:
Mailing address:
  • Phone: 208-313-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-984
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: