Provider Demographics
NPI:1316320690
Name:MACIEL, CRYSTAL (PA-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:MACIEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-4505
Mailing Address - Country:US
Mailing Address - Phone:310-549-1551
Mailing Address - Fax:
Practice Address - Street 1:1009 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-4505
Practice Address - Country:US
Practice Address - Phone:310-549-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-03
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52621363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant