Healthcare Provider Details

I. General information

NPI: 1790476802
Provider Name (Legal Business Name): ANNIKA STASA CHRYSSOS PA STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2023
Last Update Date: 03/20/2026
Certification Date: 03/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 AVALANCHE DR
DAYTON NV
89403-6383
US

IV. Provider business mailing address

140 AVALANCHE DR
DAYTON NV
89403-6383
US

V. Phone/Fax

Practice location:
  • Phone: 775-450-6946
  • Fax:
Mailing address:
  • Phone: 775-450-6946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA3327
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: