Provider Demographics
NPI:1811380231
Name:IDSTEIN, CRYSTAL (PA-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:IDSTEIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:VAHRENHOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:411 E CHESTNUT ST # 6
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1713
Practice Address - Country:US
Practice Address - Phone:502-588-9587
Practice Address - Fax:502-588-9580
Is Sole Proprietor?:No
Enumeration Date:2015-03-10
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALTA.1793363A00000X
KYPA2146363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant