Provider Demographics
NPI:1265666861
Name:DEVIVO, CRYSTAL MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:DEVIVO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:CRYSTAL
Other - Middle Name:MARIE
Other - Last Name:ROBBINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2 WESTSHIRE PL
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3375
Mailing Address - Country:US
Mailing Address - Phone:803-648-4224
Mailing Address - Fax:803-641-7600
Practice Address - Street 1:216 EDGEFIELD AVE NW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-3910
Practice Address - Country:US
Practice Address - Phone:803-648-4224
Practice Address - Fax:803-641-7600
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC821363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1055040OtherNCCPA CERTIFICATION
SC1115PAMedicaid
SCAA08639636Medicare PIN