Basic Information
| Provider Information | |||||||||
| NPI: | 1255305785 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BARKSDALE | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | CALDWELL | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1906 BELLEVIEW AVE SE | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240141838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5409817000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1930 BRAEBURN CIR | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | VA | ||||||||
| PostalCode: | 241537388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4504448100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2006 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110006501 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 004945263 | 05 | VA | MEDICAID |