Basic Information
| Provider Information | |||||||||
| NPI: | 1457767527 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CZELUSTA | ||||||||
| FirstName: | CRAIG | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 75420 | ||||||||
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| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212755420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033836469 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1104 JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | SEGUIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 781555910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8303799797 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2014 | ||||||||
| LastUpdateDate: | 01/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110004661 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.