Provider Demographics
NPI:1700338407
Name:COUTCHER, KRYSTAL (PA-C)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:
Last Name:COUTCHER
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 1:489 COMSTOCK PKWY
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02921-2345
Mailing Address - Country:US
Mailing Address - Phone:203-800-5567
Mailing Address - Fax:
Practice Address - Street 1:535 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4486
Practice Address - Country:US
Practice Address - Phone:800-659-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-28
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT23.003718363AM0700X
RIPA01257363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical