Basic Information
Provider Information
NPI: 1003140260
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MYERS
FirstName: CRAIG
MiddleName: A
NamePrefix: MR.
NameSuffix:  
Credential: PA-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: P.O. BOX 74692
Address2:  
City: CLEVELAND
State: OH
PostalCode: 441940002
CountryCode: US
TelephoneNumber: 4408955056
FaxNumber: 4403332935
Practice Location
Address1: 25200 CENTER RIDGE ROAD
Address2: SUITE 3400
City: WESTLAKE
State: OH
PostalCode: 441454145
CountryCode: US
TelephoneNumber: 4403314646
FaxNumber: 4403313197
Other Information
ProviderEnumerationDate: 09/21/2009
LastUpdateDate: 09/03/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363A00000X50.001369OHN Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 
363A00000X50-001369OHY Physician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant 

No ID Information.


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