Provider Demographics
NPI:1861798936
Name:WAAGMEESTER, CRYSTAL ANN (PA)
Entity type:Individual
Prefix:MISS
First Name:CRYSTAL
Middle Name:ANN
Last Name:WAAGMEESTER
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 1:3559 SHADY LANE CIR
Mailing Address - Street 2:
Mailing Address - City:EAST GULL LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56401-7940
Mailing Address - Country:US
Mailing Address - Phone:218-234-3101
Mailing Address - Fax:
Practice Address - Street 1:3559 SHADY LANE CIR
Practice Address - Street 2:
Practice Address - City:EAST GULL LAKE
Practice Address - State:MN
Practice Address - Zip Code:56401-7940
Practice Address - Country:US
Practice Address - Phone:218-234-3101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11309363AM0700X
WI3918-23363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical