Provider Demographics
NPI:1598775322
Name:DOLE, CRYSTAL A (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:DOLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:A
Other - Last Name:NORDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5950 METRO WAY SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9514
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5950 METRO WAY SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9514
Practice Address - Country:US
Practice Address - Phone:616-252-8180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003897363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M74460557Medicare PIN