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General NPI Number Information
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NPI Number | 1063578110
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Entity Type | Individual
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Provider Name | CRAIG JOHN CARBONNIERE SR. P.A.
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Gender | Male
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Dates
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Enumeration Date | 12/30/2006
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Last Update Date | 07/15/2015
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Provider Practice Location Address
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Address Line | 5203 LAKEWOOD BLVD
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City | LAKEWOOD
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State | CA
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Zip | 90712-2438
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Country | US
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Telephone | 562-633-2273
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Fax |
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Provider Business Mailing Address
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Address Line | 7692 ELLIS AVE
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City | HUNTINGTON BEACH
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State | CA
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Zip | 92648-1635
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Country | US
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Telephone | 909-217-4321
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA10492
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License Number State | CA
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