Basic Information
| Provider Information | |||||||||
| NPI: | 1346344041 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAIGE | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | VINCENT | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 MOW-WAY ROAD | ||||||||
| Address2: | REYNOLDS ARMY COMMUNITY HOSPITAL (ATTN: MS. PRESCOTT) | ||||||||
| City: | FT. SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735036300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804582134 | ||||||||
| FaxNumber: | 5804582314 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 MOW-WAY ROAD | ||||||||
| Address2: | REYNOLDS ARMY COMMUNITY HOSPITAL (ATTN: MS. PRESCOTT) | ||||||||
| City: | FT. SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735036300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804582134 | ||||||||
| FaxNumber: | 5804582314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2006 | ||||||||
| LastUpdateDate: | 10/24/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA05714 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 281782701 | 05 | TX | MEDICAID |