Provider Demographics
NPI:1386608107
Name:CARROLL CRIST, BETSY (PA-C)
Entity type:Individual
Prefix:
First Name:BETSY
Middle Name:
Last Name:CARROLL CRIST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:
Other - Last Name:CARROLL CRIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:420 S HILLSDALE ST
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:MI
Mailing Address - Zip Code:49245-1248
Mailing Address - Country:US
Mailing Address - Phone:517-568-4481
Mailing Address - Fax:517-568-3720
Practice Address - Street 1:420 S HILLSDALE ST
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:MI
Practice Address - Zip Code:49245-1248
Practice Address - Country:US
Practice Address - Phone:517-568-4481
Practice Address - Fax:517-568-3720
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A37669Medicare PIN
MIN82970003Medicare PIN
MIR68581Medicare UPIN
MI233974Medicare Oscar/Certification