Provider Demographics
NPI:1811195100
Name:COX, CRYSTAL J (PA)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:J
Last Name:COX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:707-521-4495
Mailing Address - Fax:707-573-5421
Practice Address - Street 1:3883 AIRWAY DR STE 120
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1678
Practice Address - Country:US
Practice Address - Phone:707-521-4495
Practice Address - Fax:707-573-5421
Is Sole Proprietor?:No
Enumeration Date:2007-07-07
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12696363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA12696OtherSTATE MEDICAL LIC