Provider Demographics
NPI:1487882403
Name:AMMERMAN, CRYSTAL MARIE
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:MARIE
Last Name:AMMERMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:AMMERMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPA-C
Mailing Address - Street 1:3775 SOUTHWESTERN BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-2159
Mailing Address - Country:US
Mailing Address - Phone:718-667-1980
Mailing Address - Fax:716-667-1982
Practice Address - Street 1:3775 SOUTHWESTERN BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2159
Practice Address - Country:US
Practice Address - Phone:718-667-1980
Practice Address - Fax:716-667-1982
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013311-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical