Provider Demographics
NPI:1164532594
Name:CRISMAN, MICHAEL PAULUS (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAULUS
Last Name:CRISMAN
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 1:502 N CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:VALENTINE
Mailing Address - State:NE
Mailing Address - Zip Code:69201-1518
Mailing Address - Country:US
Mailing Address - Phone:402-376-2200
Mailing Address - Fax:402-376-2219
Practice Address - Street 1:502 N CHERRY ST
Practice Address - Street 2:
Practice Address - City:VALENTINE
Practice Address - State:NE
Practice Address - Zip Code:69201-1518
Practice Address - Country:US
Practice Address - Phone:402-376-2200
Practice Address - Fax:402-376-2219
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1064363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47083768800Medicaid
276438Medicare ID - Type Unspecified
NE47083768800Medicaid