Provider Demographics
NPI:1932434537
Name:ROLLEG, CRYSTAL (PA-C)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:ROLLEG
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 1:18626 HARDY OAK BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4210
Mailing Address - Country:US
Mailing Address - Phone:210-495-9047
Mailing Address - Fax:210-495-9310
Practice Address - Street 1:910 E HOUSTON ST STE 270
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8367
Practice Address - Country:US
Practice Address - Phone:903-606-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-15
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP-T0929363AM0700X
TXPA10274363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1P1862OtherMEDICARE