Provider Demographics
NPI:1619133907
Name:MUMFORD, CRYSTAL (PA)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:MUMFORD
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 1:1535 GULL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-1638
Mailing Address - Country:US
Mailing Address - Phone:269-388-6350
Mailing Address - Fax:269-388-4738
Practice Address - Street 1:1535 GULL RD STE 200
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-1638
Practice Address - Country:US
Practice Address - Phone:269-388-6350
Practice Address - Fax:269-388-4738
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP080900119Medicare PIN
MIC96159091Medicare PIN