Provider Demographics
NPI:1891563862
Name:PIERCE, KRYSTAL RAE (PA)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:RAE
Last Name:PIERCE
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 1:1760 1ST AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-5223
Mailing Address - Country:US
Mailing Address - Phone:623-695-7819
Mailing Address - Fax:
Practice Address - Street 1:318 FLATBUSH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-4302
Practice Address - Country:US
Practice Address - Phone:718-398-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-19
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant