Provider Demographics
NPI:1659739936
Name:DENSMORE, CRYSTAL ANN
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:DENSMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5196 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:BOWMANSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14026-1038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5196 GENESEE ST
Practice Address - Street 2:
Practice Address - City:BOWMANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14026-1038
Practice Address - Country:US
Practice Address - Phone:716-681-1895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-02
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP00752363A00000X
NY019539363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant