Provider Demographics
NPI:1174980932
Name:NICHOLAS, CRYSTAL (PA-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:ZITTERKOPF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4000 E RENNER RD APT 1028
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75082-2732
Mailing Address - Country:US
Mailing Address - Phone:520-248-2733
Mailing Address - Fax:
Practice Address - Street 1:4000 E RENNER RD APT 1028
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75082-2732
Practice Address - Country:US
Practice Address - Phone:520-248-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10407363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant