=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407668114
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL PINEIROS PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2025
-----------------------------------------------------
Last Update Date | 02/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 805 BERGEN TOWN CTR
-----------------------------------------------------
City | PARAMUS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07652-5010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-965-1170
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 404 BERRYMAN PL
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07050-1907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-572-2689
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 032220
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 25MP00817600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------