1588659387 NPI number — MR. LOUIS T DECRISTOFARO PHYSICIAN ASSISTANT

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588659387 NPI number — MR. LOUIS T DECRISTOFARO PHYSICIAN ASSISTANT

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

DECRISTOFARO

Provider First Name:

LOUIS

Provider Middle Name:

T

Provider Name Prefix Text:

MR.

Provider Name Suffix Text:

Provider Credential Text:

PHYSICIAN ASSISTANT

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1588659387

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/23/2009

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 18029

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ASHEVILLE

Provider Business Mailing Address State Name:

NC

Provider Business Mailing Address Postal Code:

28814-0029

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

828-273-8149

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

1100 TUNNEL ROAD

Provider Second Line Business Practice Location Address:

VA MEDICAL CENTER

Provider Business Practice Location Address City Name:

ASHEVILLE

Provider Business Practice Location Address State Name:

NC

Provider Business Practice Location Address Postal Code:

28805-2043

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

828-273-8149

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

09/18/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 363A00000X , with the licence number:  A398 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363A00000X , with the licence number: 103541 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
• Taxonomy code: 363A00000X , with the licence number: 0009 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 363A00000X , with the licence number: 2669 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

• Identifier: 1012656 . This is a "NCCPA MEMBER ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 111717 . This is a "NC PA CERTIFICATION NO" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 0009 . This is a "TN PA LICENSE PHYS ASSIST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
• Identifier: A398 . This is a "SC PA LICENSE PHYS ASSIST" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
• Identifier: 0018629 . This is a "AAPA MEMBER ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 103541 . This is a "NC PA LICENSE PHYS ASSIST" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
• Identifier: 2669 . This is a "GA PA LICENSE PHYS ASSIST" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".