Provider Demographics
NPI:1811171267
Name:FOOTE, CRYSTINA C (PA-C)
Entity type:Individual
Prefix:
First Name:CRYSTINA
Middle Name:C
Last Name:FOOTE
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 1:405 S MORRISON RD
Mailing Address - Street 2:APT 120
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4043
Mailing Address - Country:US
Mailing Address - Phone:317-966-9832
Mailing Address - Fax:
Practice Address - Street 1:2525 W UNIVERSITY AVE
Practice Address - Street 2:SUITE 503
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3421
Practice Address - Country:US
Practice Address - Phone:765-288-0441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-20
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN465820OtherMEDICARE PROVIDER