Provider Demographics
NPI:1437818523
Name:BECERRA, CRYSTAL MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:MICHELLE
Last Name:BECERRA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:CRYSTAL
Other - Middle Name:MICHELLE
Other - Last Name:THAYER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1089 TREADWELL AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-5039
Mailing Address - Country:US
Mailing Address - Phone:805-304-6018
Mailing Address - Fax:
Practice Address - Street 1:1089 TREADWELL AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-5039
Practice Address - Country:US
Practice Address - Phone:805-304-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA60380363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant