Provider Demographics
NPI:1053361956
Name:CRUMLISH, MARY ANN (PA-C)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:CRUMLISH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2744 GULF BREEZE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-3091
Mailing Address - Country:US
Mailing Address - Phone:850-934-5713
Mailing Address - Fax:850-934-0379
Practice Address - Street 1:2744 GULF BREEZE PARKWAY
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-2908
Practice Address - Country:US
Practice Address - Phone:850-934-5713
Practice Address - Fax:850-934-0379
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102271363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCE8826ZMedicare ID - Type Unspecified
FLR40512Medicare UPIN
FLE8826XMedicare ID - Type Unspecified