Provider Demographics
NPI:1760469514
Name:CRISS, CHARLENE ROBERTA THOMPSON (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:ROBERTA THOMPSON
Last Name:CRISS
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:USCG HQ CG-1121 2703 MLK JR AVE SE MAIL STOP 7907
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20593-7907
Mailing Address - Country:US
Mailing Address - Phone:202-475-5183
Mailing Address - Fax:270-294-3610
Practice Address - Street 1:15 MOHEGAN AVE
Practice Address - Street 2:USCG ACADEMY CLINIC
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-701-6737
Practice Address - Fax:860-701-6475
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2020-04-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN1710363AM0700X
CT001831363AM0700X
NJMP00120900363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1051820OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
CT001831OtherPHYSICIAN ASSISTANT