MEDICARE: CRISTAL BOATRIGHT PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9105271	FL

General Provider Information

NPI Number	:	1235670621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRISTAL BOATRIGHT PA-C

Provider Business Mailing Address
First Line	:	7741 POINT MEADOWS DR
Second Line	:	UNIT 104
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-9201
Country	:	US
Telephone Number	:	904-660-2330
Fax Number	:

Provider Business Practice Location Address
First Line	:	7741 POINT MEADOWS DR
Second Line	:	UNIT 104
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-9201
Country	:	US
Telephone Number	:	904-660-2330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2017
Last Update Date	:	08/21/2017

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