Healthcare Provider Details

I. General information

NPI: 1871717959
Provider Name (Legal Business Name): JANE CRIDLAND MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 N BALLAS RD STE 365 C
SAINT LOUIS MO
63131-2322
US

IV. Provider business mailing address

7007 MARYLAND AVE
SAINT LOUIS MO
63130-4415
US

V. Phone/Fax

Practice location:
  • Phone: 314-991-0137
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number110580
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: