Provider Demographics
NPI:1003577768
Name:MARTIN, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MARTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6001 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE
Mailing Address - State:CA
Mailing Address - Zip Code:90040-2451
Mailing Address - Country:US
Mailing Address - Phone:562-928-9600
Mailing Address - Fax:
Practice Address - Street 1:6501 GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:BELL GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90201-1805
Practice Address - Country:US
Practice Address - Phone:562-928-9600
Practice Address - Fax:562-927-6803
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA951641454Medicaid