Healthcare Provider Details

I. General information

NPI: 1932434537
Provider Name (Legal Business Name): CRYSTAL ROLLEG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2009
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 E HOUSTON ST STE 270
TYLER TX
75702-8367
US

IV. Provider business mailing address

18626 HARDY OAK BLVD SUITE 300
SAN ANTONIO TX
78258-4210
US

V. Phone/Fax

Practice location:
  • Phone: 903-606-4300
  • Fax:
Mailing address:
  • Phone: 210-495-9047
  • Fax: 210-495-9310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberP-T0929
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10274
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: