Provider Demographics
NPI:1508861923
Name:KRYSTOFF, NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:KRYSTOFF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:CONRAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3910 CAUGHEY RD STE 150
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-4041
Mailing Address - Country:US
Mailing Address - Phone:814-877-5401
Mailing Address - Fax:814-877-5400
Practice Address - Street 1:3910 CAUGHEY RD STE 150
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506-4041
Practice Address - Country:US
Practice Address - Phone:814-877-5401
Practice Address - Fax:814-877-5400
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA002105254OtherHIGHMARK
PA090722Medicare PIN
PA002105254OtherHIGHMARK