Provider Demographics
NPI:1255017893
Name:MINER, KRYSTAL (ABOC)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:MINER
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:SHAMOKIN
Mailing Address - State:PA
Mailing Address - Zip Code:17872-5365
Mailing Address - Country:US
Mailing Address - Phone:570-809-3893
Mailing Address - Fax:
Practice Address - Street 1:233 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:SHAMOKIN
Practice Address - State:PA
Practice Address - Zip Code:17872-5365
Practice Address - Country:US
Practice Address - Phone:570-809-3893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA252252156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician