Provider Demographics
NPI:1649303629
Name:CRISS, ADELE ELIZABETH (PA)
Entity type:Individual
Prefix:
First Name:ADELE
Middle Name:ELIZABETH
Last Name:CRISS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14650 EAST OLD US HIGHWAY 12
Mailing Address - Street 2:SUITE 308
Mailing Address - City:CHELSEA
Mailing Address - State:MI
Mailing Address - Zip Code:48118
Mailing Address - Country:US
Mailing Address - Phone:734-475-3221
Mailing Address - Fax:734-475-6411
Practice Address - Street 1:14650 EAST OLD US HIGHWAY 12
Practice Address - Street 2:SUITE 308
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118
Practice Address - Country:US
Practice Address - Phone:734-475-3221
Practice Address - Fax:734-475-6411
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003968363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00700001Medicare ID - Type Unspecified