Provider Demographics
NPI:1275943821
Name:KOHISTANI, CRYSTAL H (PA-C, MPAS)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:H
Last Name:KOHISTANI
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 FAIRVIEW ST
Mailing Address - Street 2:
Mailing Address - City:SILVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97381-1916
Mailing Address - Country:US
Mailing Address - Phone:503-873-8686
Mailing Address - Fax:503-873-8689
Practice Address - Street 1:335 FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:SILVERTON
Practice Address - State:OR
Practice Address - Zip Code:97381-1916
Practice Address - Country:US
Practice Address - Phone:503-873-8686
Practice Address - Fax:503-873-8689
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA176406363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical