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General NPI Number Information
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NPI Number | 1629535307
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Entity Type | Individual
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Provider Name | COURTNEY RAE CRISWELL PA-C
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Gender | Female
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Dates
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Enumeration Date | 02/28/2019
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Last Update Date | 09/20/2024
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Provider Practice Location Address
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Address Line | 5191 FIRST COAST TECH PKWY FL 3
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City | JACKSONVILLE
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State | FL
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Zip | 32224-0609
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Country | US
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Telephone | 904-223-3321
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Fax | 904-223-2169
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Provider Business Mailing Address
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Address Line | 5191 FIRST COAST TECH PKWY FL 3
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City | JACKSONVILLE
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State | FL
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Zip | 32224-0609
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Country | US
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Telephone | 904-223-3321
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Fax | 904-223-2169
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9111862
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 10406
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License Number State | GA
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