Provider Demographics
NPI:1962557892
Name:CRAIG, MONIQUE ROXANNE (PA)
Entity type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:ROXANNE
Last Name:CRAIG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8705 S 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-2411
Mailing Address - Country:US
Mailing Address - Phone:323-449-0177
Mailing Address - Fax:
Practice Address - Street 1:301 N PRAIRIE AVE STE 210
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4509
Practice Address - Country:US
Practice Address - Phone:310-677-8545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 14143363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14143OtherCA. P.A LICENSE