=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487926218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN LEE CRADDICK PA-C, MPAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2012
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1867 AIRPORT FRONTAGE ROAD SUITE B (U.S. HEALTHWORKS ALASKA)
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-1867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-452-2178
-----------------------------------------------------
Fax | 907-452-3178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1867 AIRPORT FRONTAGE ROAD SUITE B (U.S. HEALTHWORKS ALASKA)
-----------------------------------------------------
City | FAIRBANKS
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99701-1867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-452-2178
-----------------------------------------------------
Fax | 907-452-3178
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 250
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------