Basic Information
| Provider Information | |||||||||
| NPI: | 1659874774 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COCOROS | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DR | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073644445 | ||||||||
| FaxNumber: | 9073644487 | ||||||||
| Practice Location | |||||||||
| Address1: | 1046 SALMON CREEK LANE | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073644445 | ||||||||
| FaxNumber: | 9073644487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2018 | ||||||||
| LastUpdateDate: | 03/15/2018 | ||||||||
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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 | 106S00000X | Y |
No ID Information.