Provider Demographics
NPI:1699052357
Name:KANTACK, CRAIG STEPHEN (PA-C)
Entity type:Individual
Prefix:MR
First Name:CRAIG
Middle Name:STEPHEN
Last Name:KANTACK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:944 W 97TH S
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-5842
Mailing Address - Country:US
Mailing Address - Phone:208-313-5150
Mailing Address - Fax:
Practice Address - Street 1:740 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-5285
Practice Address - Country:US
Practice Address - Phone:208-542-9111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-984363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical