MEDICARE: CRYSTAL PACANOWSKI M.D.

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	207V00000X	Obstetrics & Gynecology Physician	R74354	AZ

General Provider Information

NPI Number	:	1275946717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL PACANOWSKI M.D.

Provider Business Mailing Address
First Line	:	1501 N CAMPBELL AVE
Second Line	:	PO BOX 245078
City	:	TUCSON
State	:	AZ
Zip	:	85724-5078
Country	:	US
Telephone Number	:	520-626-6636
Fax Number	:	520-626-1446

Provider Business Practice Location Address
First Line	:	1501 N CAMPBELL AVE
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85724-5078
Country	:	US
Telephone Number	:	520-626-6636
Fax Number	:	520-626-1446

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

Provider Enumeration Date	:	06/03/2014
Last Update Date	:	12/04/2018

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