Basic Information
| Provider Information | |||||||||
| NPI: | 1588174882 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRESLOW | ||||||||
| FirstName: | KRYSTAL | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2652 S PALOMA AVE | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853658907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802014126 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1006 E GUADALUPE RD | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852833047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808384296 | ||||||||
| FaxNumber: | 4808201275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2017 | ||||||||
| LastUpdateDate: | 03/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 6793 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 316914 | 05 | AZ | MEDICAID |