Provider Demographics
NPI:1962081810
Name:ODEGARD, CRYSTAL NOEL (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:NOEL
Last Name:ODEGARD
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 1:1652 W SUNNY SLOPE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4336
Mailing Address - Country:US
Mailing Address - Phone:541-285-4851
Mailing Address - Fax:
Practice Address - Street 1:1079 S ANCONA AVE STE 100
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-7443
Practice Address - Country:US
Practice Address - Phone:208-853-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant