MEDICARE: KRISTINA MARIE CRESPO 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

General Provider Information

NPI Number	:	1962123075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA MARIE CRESPO PA-C

Provider Business Mailing Address
First Line	:	88 E MONAVILLE RD
Second Line	:
City	:	LAKE VILLA
State	:	IL
Zip	:	60046-9155
Country	:	US
Telephone Number	:	219-433-7763
Fax Number	:

Provider Business Practice Location Address
First Line	:	1245 E IRELAND RD
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46614-3448
Country	:	US
Telephone Number	:	574-312-7022
Fax Number	:

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

Provider Enumeration Date	:	09/07/2022
Last Update Date	:	09/07/2022

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