Provider Demographics
NPI:1508107657
Name:KITTISOPIKUL, CRYSTAL (PA)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:KITTISOPIKUL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 N MACARTHUR BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-2219
Mailing Address - Country:US
Mailing Address - Phone:972-253-2515
Mailing Address - Fax:972-253-4217
Practice Address - Street 1:2021 N MACARTHUR BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-2219
Practice Address - Country:US
Practice Address - Phone:972-253-2515
Practice Address - Fax:972-253-4217
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical