Provider Demographics
NPI:1962123075
Name:CRESPO, KRISTINA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:CRESPO
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 1:88 E MONAVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046-9155
Mailing Address - Country:US
Mailing Address - Phone:219-433-7763
Mailing Address - Fax:
Practice Address - Street 1:1245 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-3448
Practice Address - Country:US
Practice Address - Phone:574-312-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant