Provider Demographics
NPI:1699259705
Name:MING, CRYSTAL STACY (PA-C)
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:STACY
Last Name:MING
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 1:320 THE VLG UNIT 211
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-2613
Mailing Address - Country:US
Mailing Address - Phone:954-651-3059
Mailing Address - Fax:
Practice Address - Street 1:22330 HAWTHORNE BLVD STE J
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-2551
Practice Address - Country:US
Practice Address - Phone:954-651-3059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55778363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant