Provider Demographics
NPI:1942721642
Name:MAC, CRYSTAL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:MAC
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 1:1218 EDITH AVE APT G
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91803-2476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 N SEPULVEDA BLVD STE 210
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-6849
Practice Address - Country:US
Practice Address - Phone:310-379-2134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-03
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant