Provider Demographics
NPI:1477067775
Name:BURTIS, CRYSTAL ANNE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANNE
Last Name:BURTIS
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 N 200 E STE 160
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-3175
Mailing Address - Country:US
Mailing Address - Phone:435-750-5599
Mailing Address - Fax:435-750-0861
Practice Address - Street 1:1624 N 200 E STE 160
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-3175
Practice Address - Country:US
Practice Address - Phone:435-750-5599
Practice Address - Fax:435-750-0861
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-22
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1054788-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant