MEDICARE: CRYSTAL NICOLE MANN P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0110001941	VA
2	363A00000X	Physician Assistant	031359	DC

General Provider Information

NPI Number	:	1114988854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL NICOLE MANN P.A.

Provider Business Mailing Address
First Line	:	130 SUTTER ST FL 2
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94104-4009
Country	:	US
Telephone Number	:	415-658-6791
Fax Number	:	415-520-0904

Provider Business Practice Location Address
First Line	:	1827 ADAMS MILL RD NW STE C
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20009-1901
Country	:	US
Telephone Number	:	202-627-1903
Fax Number	:	202-660-0025

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2006
Last Update Date	:	11/24/2021

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