Healthcare Provider Details

I. General information

NPI: 1720151764
Provider Name (Legal Business Name): MS. CRYSTAL ANN GRUND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL DVORAK

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 SAN ANTONIO RD
MOUNTAIN VIEW CA
94040-1209
US

IV. Provider business mailing address

1691 THE ALAMEDA
SAN JOSE CA
95126-2203
US

V. Phone/Fax

Practice location:
  • Phone: 650-948-0807
  • Fax: 650-948-3319
Mailing address:
  • Phone: 408-795-3619
  • Fax: 408-287-0405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA18026
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: