Provider Demographics
NPI:1962265199
Name:LATHEN, CRAIG LARRY (FNP)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:LARRY
Last Name:LATHEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 116
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89831-0116
Mailing Address - Country:US
Mailing Address - Phone:208-851-2472
Mailing Address - Fax:
Practice Address - Street 1:1623 HOSPITAL LOOP
Practice Address - Street 2:
Practice Address - City:OWYHEE
Practice Address - State:NV
Practice Address - Zip Code:89832-1200
Practice Address - Country:US
Practice Address - Phone:775-757-2415
Practice Address - Fax:775-757-3010
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID55861363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner