Healthcare Provider Details

I. General information

NPI: 1265666861
Provider Name (Legal Business Name): CRYSTAL MARIE DEVIVO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL MARIE ROBBINS PA-C

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 EDGEFIELD AVE NW
AIKEN SC
29801-3910
US

IV. Provider business mailing address

2 WESTSHIRE PL
NORTH AUGUSTA SC
29841-3375
US

V. Phone/Fax

Practice location:
  • Phone: 803-648-4224
  • Fax: 803-641-7600
Mailing address:
  • Phone: 803-648-4224
  • Fax: 803-641-7600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number821
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: