Provider Demographics
NPI:1538132899
Name:KRYSL, CHARLES J (PA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:J
Last Name:KRYSL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E H ST
Mailing Address - Street 2:
Mailing Address - City:MC COOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-3432
Mailing Address - Country:US
Mailing Address - Phone:308-344-4110
Mailing Address - Fax:308-344-8369
Practice Address - Street 1:1401 E H ST
Practice Address - Street 2:
Practice Address - City:MC COOK
Practice Address - State:NE
Practice Address - Zip Code:69001-3432
Practice Address - Country:US
Practice Address - Phone:308-344-4110
Practice Address - Fax:308-344-8369
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE840363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470748011-12Medicaid