Provider Demographics
NPI:1407209828
Name:MITICH, KRYSTAL A (PA-C)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:A
Last Name:MITICH
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 1:1821 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-2253
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:1821 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-2253
Practice Address - Country:US
Practice Address - Phone:920-496-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4248-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant