Basic Information
| Provider Information | |||||||||
| NPI: | 1235689100 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADDISON | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3621 S STATE ST | ||||||||
| Address2: | 700 KMS PLACE | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349362047 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E MEDICAL CENTER DRIVE | ||||||||
| Address2: | LEVEL 4 UNIVERSITY HOSPITAL BLDG 1000312 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346479291 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2016 | ||||||||
| LastUpdateDate: | 02/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 5601008004 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.