Provider Demographics
NPI:1508107657
Name:KITTISOPIKUL, CRYSTAL L (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:L
Last Name:KITTISOPIKUL
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 1:19455 DEERFIELD AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176
Mailing Address - Country:US
Mailing Address - Phone:703-858-9608
Mailing Address - Fax:703-858-9618
Practice Address - Street 1:19455 DEERFIELD AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176
Practice Address - Country:US
Practice Address - Phone:703-858-9608
Practice Address - Fax:703-858-9618
Is Sole Proprietor?:No
Enumeration Date:2013-03-13
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007265363AM0700X
TX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical