Healthcare Provider Details

I. General information

NPI: 1528597341
Provider Name (Legal Business Name): MISS CARLIE ANN CRAVEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 N WASHINGTON AVE
SCRANTON PA
18509-2913
US

IV. Provider business mailing address

1032 N WASHINGTON AVE
SCRANTON PA
18509-2913
US

V. Phone/Fax

Practice location:
  • Phone: 570-558-8660
  • Fax: 570-558-6147
Mailing address:
  • Phone: 570-558-8660
  • Fax: 570-558-6147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA059374
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA004282
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: