Provider Demographics
NPI:1730287350
Name:MCCRYSTAL, KEVIN THOMAS (PAC)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:THOMAS
Last Name:MCCRYSTAL
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 MAPLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066
Mailing Address - Country:US
Mailing Address - Phone:860-875-7915
Mailing Address - Fax:
Practice Address - Street 1:81 MENDEN AVENUE
Practice Address - Street 2:BRADLEY MEMORIAL HOSPITAL
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489
Practice Address - Country:US
Practice Address - Phone:860-276-5208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400000182Medicare PIN