Healthcare Provider Details

I. General information

NPI: 1275964504
Provider Name (Legal Business Name): CRAIG ALLEN RODRIGUEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 N MAIN ST
RICHFIELD UT
84701-1840
US

IV. Provider business mailing address

861 N MAIN ST
RICHFIELD UT
84701-1840
US

V. Phone/Fax

Practice location:
  • Phone: 435-558-7031
  • Fax: 702-576-9609
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12256467-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1471
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: