Provider Demographics
NPI:1881845824
Name:MEREDITH, CRYSTAL RUDDELL (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:RUDDELL
Last Name:MEREDITH
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 1:187 NINTH STREET
Mailing Address - Street 2:P.O. BOX 2780
Mailing Address - City:JENA
Mailing Address - State:LA
Mailing Address - Zip Code:71342-2780
Mailing Address - Country:US
Mailing Address - Phone:318-992-9200
Mailing Address - Fax:318-992-9245
Practice Address - Street 1:187 NINTH STREET
Practice Address - Street 2:
Practice Address - City:JENA
Practice Address - State:LA
Practice Address - Zip Code:71342
Practice Address - Country:US
Practice Address - Phone:318-992-9296
Practice Address - Fax:318-992-9125
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200237363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical