Provider Demographics
NPI:1184655094
Name:POWELL, CRYSTAL JEAN (MPAS, PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JEAN
Last Name:POWELL
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:JEAN
Other - Last Name:PETTIT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 802843
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64180-2843
Mailing Address - Country:US
Mailing Address - Phone:417-730-6430
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:3850 S NATIONAL AVE STE 400
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5287
Practice Address - Country:US
Practice Address - Phone:417-269-7290
Practice Address - Fax:417-269-7297
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006005289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant