Provider Demographics
NPI:1639285430
Name:GAY, CRYSTAL D (PA)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:D
Last Name:GAY
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 1:2406 LIGHTHOUSE MANOR DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-7401
Mailing Address - Country:US
Mailing Address - Phone:770-536-4352
Mailing Address - Fax:770-532-8165
Practice Address - Street 1:1235 FRIENDSHIP RD STE 100
Practice Address - Street 2:
Practice Address - City:BRASELTON
Practice Address - State:GA
Practice Address - Zip Code:30517-5624
Practice Address - Country:US
Practice Address - Phone:770-536-4352
Practice Address - Fax:770-532-8165
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3248363AM0700X
GA003248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4727OtherGROUP PROVIDER ID
GAS72501Medicare UPIN
GA97WCGWQMedicare ID - Type Unspecified