Basic Information
| Provider Information | |||||||||
| NPI: | 1508023151 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISTALES | ||||||||
| FirstName: | MIRANDA | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 804 SERVICE RD | ||||||||
| Address2: | A201 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488247015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178842976 | ||||||||
| FaxNumber: | 5174323928 | ||||||||
| Practice Location | |||||||||
| Address1: | 4660 S HAGADORN RD | ||||||||
| Address2: | #600 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235376 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172672460 | ||||||||
| FaxNumber: | 5178848602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 06/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 5601005230 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 1508023151 | 05 | MI | MEDICAID | 5601005230 | 01 | MI | STATE LICENSE | OTHER |