1811195100 NPI number — CRYSTAL J COX PA

Table of content: CRYSTAL J COX PA (NPI 1811195100)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811195100 NPI number — CRYSTAL J COX PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COX
Provider First Name:
CRYSTAL
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811195100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 DISTEL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ALTOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94022-1408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-521-4495
Provider Business Mailing Address Fax Number:
707-573-5421

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3883 AIRWAY DR STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95403-1678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-521-4495
Provider Business Practice Location Address Fax Number:
707-573-5421
Provider Enumeration Date:
07/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  12696 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA12696 . This is a "STATE MEDICAL LIC" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com