Basic Information
| Provider Information | |||||||||
| NPI: | 1811171267 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOOTE | ||||||||
| FirstName: | CRYSTINA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 405 S MORRISON RD | ||||||||
| Address2: | APT 120 | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473044043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179669832 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2525 W UNIVERSITY AVE | ||||||||
| Address2: | SUITE 503 | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473033421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652880441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2007 | ||||||||
| LastUpdateDate: | 06/02/2008 | ||||||||
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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 | 363AS0400X | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 465820 | 01 | IN | MEDICARE PROVIDER | OTHER |