Provider Demographics
NPI:1356389514
Name:SMITH, CRYSTAL (PA)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:509 MEMORIAL DR
Mailing Address - Street 2:STE 2
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6196
Mailing Address - Country:US
Mailing Address - Phone:606-598-8813
Mailing Address - Fax:606-598-1688
Practice Address - Street 1:509 MEMORIAL DR
Practice Address - Street 2:SUITE 2
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-6195
Practice Address - Country:US
Practice Address - Phone:606-598-8813
Practice Address - Fax:606-598-1688
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYPA792363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95003737Medicaid
P00648835OtherRR MEDICARE
KY000000522080OtherANTHEM BCBS
KY000000522080OtherANTHEM BCBS
KY95003737Medicaid