Provider Demographics
NPI:1205849973
Name:COTRELL, CRYSTAL KERSEY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:KERSEY
Last Name:COTRELL
Suffix:
Gender:F
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 1:58 BIG A RD
Mailing Address - Street 2:
Mailing Address - City:TOCCOA
Mailing Address - State:GA
Mailing Address - Zip Code:30577-6017
Mailing Address - Country:US
Mailing Address - Phone:706-282-4200
Mailing Address - Fax:706-886-8045
Practice Address - Street 1:58 BIG A RD
Practice Address - Street 2:
Practice Address - City:TOCCOA
Practice Address - State:GA
Practice Address - Zip Code:30577
Practice Address - Country:US
Practice Address - Phone:706-282-4200
Practice Address - Fax:706-886-8045
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004427363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA620119937CMedicaid
GA511I970390Medicare PIN
GAQ39391Medicare UPIN
MC1173525OtherDEA
GA004427OtherSTATE LICENSE