Healthcare Provider Details

I. General information

NPI: 1629024179
Provider Name (Legal Business Name): CRAIG N. AMBROSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 03/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 8TH ST
LEWISTON ID
83501-7301
US

IV. Provider business mailing address

2315 8TH ST
LEWISTON ID
83501-7301
US

V. Phone/Fax

Practice location:
  • Phone: 208-746-1383
  • Fax: 208-746-6348
Mailing address:
  • Phone: 208-746-1383
  • Fax: 208-746-6348

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM4939
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD00040671
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: