Provider Demographics
NPI:1346785862
Name:PEREZ, CRYSTAL MONIQUE
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MONIQUE
Last Name:PEREZ
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 1:815 E COLORADO ST STE 110A
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205-1200
Mailing Address - Country:US
Mailing Address - Phone:818-242-1910
Mailing Address - Fax:
Practice Address - Street 1:815 E COLORADO ST STE 110A
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91205-1200
Practice Address - Country:US
Practice Address - Phone:818-242-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53849363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant