Provider Demographics
NPI:1497900591
Name:MORRISSEY, CRYSTAL (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MORRISSEY
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 1:121 N PINE RIVER ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:MI
Mailing Address - Zip Code:48847-1039
Mailing Address - Country:US
Mailing Address - Phone:989-875-5111
Mailing Address - Fax:989-875-5023
Practice Address - Street 1:121 N PINE RIVER ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-1039
Practice Address - Country:US
Practice Address - Phone:989-875-5111
Practice Address - Fax:989-875-5023
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI085331620OtherBCBSM
MIM02890003Medicare PIN
MI085331620OtherBCBSM
MIP14270006Medicare PIN