Basic Information
| Provider Information | |||||||||
| NPI: | 1891753497 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LASTINE | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | LELLAND | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 308 | ||||||||
| Address2: | |||||||||
| City: | MONTROSE | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814020308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704978416 | ||||||||
| FaxNumber: | 9704978410 | ||||||||
| Practice Location | |||||||||
| Address1: | 2021 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815012980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702420920 | ||||||||
| FaxNumber: | 4065871343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
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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 | 2085R0202X | DR.0044010 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 152524 | 05 | MT | MEDICAID | 06350003 | 05 | CO | MEDICAID | 0152507 | 05 | MT | MEDICAID |