Healthcare Provider Details

I. General information

NPI: 1841496643
Provider Name (Legal Business Name): CRYSTAL M KANASKIE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 SAINT PAUL ST 5TH FLOOR
BALTIMORE MD
21202-2001
US

IV. Provider business mailing address

301 SAINT PAUL ST TIDEPOINT-CREDENTIALING
BALTIMORE MD
21202-2102
US

V. Phone/Fax

Practice location:
  • Phone: 410-332-9002
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0003528
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: