Healthcare Provider Details

I. General information

NPI: 1902036775
Provider Name (Legal Business Name): CHRYSTAL MARIE PILGRIM PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 04/18/2022
Certification Date: 04/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 ROCKVILLE PIKE
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

705 HAWKINS WAY
ALEXANDRIA VA
22314-6201
US

V. Phone/Fax

Practice location:
  • Phone: 301-400-1356
  • Fax:
Mailing address:
  • Phone: 210-867-3466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC00006383
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: