Provider Demographics
NPI:1780641233
Name:GRIMES, CRYSTAL L (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:GRIMES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10202 W 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-4377
Mailing Address - Country:US
Mailing Address - Phone:316-729-9100
Mailing Address - Fax:316-729-9185
Practice Address - Street 1:10202 W 13TH ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-4377
Practice Address - Country:US
Practice Address - Phone:316-729-9100
Practice Address - Fax:316-729-9185
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00627363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200003740 AMedicaid
003719196OtherMEDICARE
003719196OtherMEDICARE