Provider Demographics
NPI:1063578110
Name:CARBONNIERE, CRAIG JOHN SR (PA)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:JOHN
Last Name:CARBONNIERE
Suffix:SR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7692 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-1635
Mailing Address - Country:US
Mailing Address - Phone:909-217-4321
Mailing Address - Fax:
Practice Address - Street 1:5203 LAKEWOOD BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-2438
Practice Address - Country:US
Practice Address - Phone:562-633-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10492363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant