Basic Information
| Provider Information | |||||||||
| NPI: | 1205849973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COTRELL | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | KERSEY | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 58 BIG A RD | ||||||||
| Address2: | |||||||||
| City: | TOCCOA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305776017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062824200 | ||||||||
| FaxNumber: | 7068868045 | ||||||||
| Practice Location | |||||||||
| Address1: | 58 BIG A RD | ||||||||
| Address2: | |||||||||
| City: | TOCCOA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062824200 | ||||||||
| FaxNumber: | 7068868045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 08/26/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 004427 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 620119937C | 05 | GA | MEDICAID |