Healthcare Provider Details

I. General information

NPI: 1053756288
Provider Name (Legal Business Name): CRYSTAL L. HOPE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR STREET HARTFORD HOSPITAL SURGERY DEPT
HARTFORD CT
06102-5037
US

IV. Provider business mailing address

PO BOX 415933 HARTFORD HOSPITAL PROFESSIONAL SERVICES
BOSTON MA
02241-5933
US

V. Phone/Fax

Practice location:
  • Phone: 860-972-4670
  • Fax:
Mailing address:
  • Phone: 860-972-9047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-04193
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003075
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003075
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003075
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: