MEDICARE: MISS CRYSTAL ANN WAAGMEESTER PA

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	363AM0700X	Medical Physician Assistant	11309	MN
2	363AM0700X	Medical Physician Assistant	3918-23	WI

General Provider Information

NPI Number	:	1861798936
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS CRYSTAL ANN WAAGMEESTER PA

Provider Business Mailing Address
First Line	:	3559 SHADY LANE CIR
Second Line	:
City	:	EAST GULL LAKE
State	:	MN
Zip	:	56401-7940
Country	:	US
Telephone Number	:	218-234-3101
Fax Number	:

Provider Business Practice Location Address
First Line	:	3559 SHADY LANE CIR
Second Line	:
City	:	EAST GULL LAKE
State	:	MN
Zip	:	56401-7940
Country	:	US
Telephone Number	:	218-234-3101
Fax Number	:

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

Provider Enumeration Date	:	02/07/2011
Last Update Date	:	10/05/2016

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