Provider Demographics
NPI:1497980668
Name:MARTIN, KRYSTAL ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:ANN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRYSTAL
Other - Middle Name:ANN
Other - Last Name:BAGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:325 E EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-3364
Practice Address - Country:US
Practice Address - Phone:734-936-7175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-18
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008250363A00000X, 363A00000X
MI5501013733314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility