Basic Information
| Provider Information | |||||||||
| NPI: | 1477717130 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERGUSON | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | RANDALL | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 90TH AVE SE | ||||||||
| Address2: | #258 | ||||||||
| City: | MERCER ISLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980403146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2062407998 | ||||||||
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| Practice Location | |||||||||
| Address1: | 955 POWELL AVE SW | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980572908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252030432 | ||||||||
| FaxNumber: | 4252771566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2008 | ||||||||
| LastUpdateDate: | 12/08/2008 | ||||||||
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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 | 363LF0000X | PENDING | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9658030 | 05 | WA | MEDICAID |