Provider Demographics
NPI:1760505192
Name:STORDAHL, CRYSTAL LEE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:LEE
Last Name:STORDAHL
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:201 1ST AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4848
Mailing Address - Country:US
Mailing Address - Phone:907-452-8251
Mailing Address - Fax:907-459-3978
Practice Address - Street 1:1408 19TH AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-5903
Practice Address - Country:US
Practice Address - Phone:907-452-8251
Practice Address - Fax:907-459-3978
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK518363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical