Basic Information
| Provider Information | |||||||||
| NPI: | 1710088778 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WARREN | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5416 22ND AVE SE | ||||||||
| Address2: | |||||||||
| City: | LACEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985032804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604557397 | ||||||||
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| Practice Location | |||||||||
| Address1: | 525 LILLY RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604937230 | ||||||||
| FaxNumber: | 3604934180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207Q00000X | OP00002136 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BW8934677 | 01 | WA | DEA | OTHER |