Provider Demographics
NPI:1912304015
Name:MOON, CRYSTAL ELAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ELAINE
Last Name:MOON
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 1:645 PAUL HUFF PARKWAY NW
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312
Mailing Address - Country:US
Mailing Address - Phone:423-790-4420
Mailing Address - Fax:423-790-7750
Practice Address - Street 1:961 SPRING CREEK RD STE 300
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37412
Practice Address - Country:US
Practice Address - Phone:423-893-9787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2666363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical