Healthcare Provider Details

I. General information

NPI: 1194724146
Provider Name (Legal Business Name): LINDA L CRISWELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 10/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 E ATWATER AVE
EUSTIS FL
32726-5540
US

IV. Provider business mailing address

39 E ATWATER AVE
EUSTIS FL
32726-5540
US

V. Phone/Fax

Practice location:
  • Phone: 352-483-0900
  • Fax: 352-483-0822
Mailing address:
  • Phone: 352-483-0900
  • Fax: 352-483-0822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9101054
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101054
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: