Healthcare Provider Details

I. General information

NPI: 1750884391
Provider Name (Legal Business Name): KRYSTAL S MCCAIN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 6TH ST
MODESTO CA
95354-2203
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 209-576-2845
  • Fax: 209-576-8842
Mailing address:
  • Phone: 209-384-6481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.1331
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: