Provider Demographics
NPI:1588174882
Name:BRESLOW, KRYSTAL (PA)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:BRESLOW
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 1:2652 S PALOMA AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-8907
Mailing Address - Country:US
Mailing Address - Phone:480-201-4126
Mailing Address - Fax:
Practice Address - Street 1:1006 E GUADALUPE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3047
Practice Address - Country:US
Practice Address - Phone:480-838-4296
Practice Address - Fax:480-820-1275
Is Sole Proprietor?:No
Enumeration Date:2017-10-02
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6793363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ316914Medicaid