Provider Demographics
NPI:1023496965
Name:DALE, CRAIG
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:
Last Name:DALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CRAIG
Other - Middle Name:
Other - Last Name:DALE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:441 N TENMILE LK
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97449-8648
Mailing Address - Country:US
Mailing Address - Phone:719-239-1403
Mailing Address - Fax:
Practice Address - Street 1:441 N TENMILE LK
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:OR
Practice Address - Zip Code:97449-8648
Practice Address - Country:US
Practice Address - Phone:719-239-1403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-12
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA179589363A00000X
WAPA60843540363A00000X
IDPA1619363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant