Provider Demographics
NPI:1538799747
Name:CALLAM, CRAIG F (APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:F
Last Name:CALLAM
Suffix:
Gender:M
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11980 MOUNT VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5172
Mailing Address - Country:US
Mailing Address - Phone:909-864-1097
Mailing Address - Fax:512-256-8799
Practice Address - Street 1:11555 1/2 POTRERO RD
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6946
Practice Address - Country:US
Practice Address - Phone:951-849-4761
Practice Address - Fax:951-849-4651
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2024-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9365661163W00000X
CA95239375363LF0000X
FLAPRN11006675363LF0000X
FL11006675363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty