Provider Demographics
NPI:1386848810
Name:GUNN, CRYSTAL LEE (PA)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LEE
Last Name:GUNN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 E HILL CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:NY
Mailing Address - Zip Code:14801-9648
Mailing Address - Country:US
Mailing Address - Phone:724-762-3697
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-887-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051691363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03319775Medicaid
NY03319775Medicaid