Healthcare Provider Details

I. General information

NPI: 1942245691
Provider Name (Legal Business Name): CRYSTAL MARIE QURESHI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL MARIE SULLIVAN

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14044 W CAMELBACK RD STE 204
LITCHFIELD PARK AZ
85340-9426
US

IV. Provider business mailing address

14044 W CAMELBACK RD STE 204
LITCHFIELD PARK AZ
85340-9426
US

V. Phone/Fax

Practice location:
  • Phone: 623-935-9600
  • Fax: 623-935-9602
Mailing address:
  • Phone: 623-935-9600
  • Fax: 623-935-9602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3244
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: