Provider Demographics
NPI:1487120077
Name:CRISCI, NICHOLAS JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:CRISCI
Suffix:
Gender:M
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 1:2325 E RIO SALADO PKWY
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281-7489
Mailing Address - Country:US
Mailing Address - Phone:480-388-9133
Mailing Address - Fax:
Practice Address - Street 1:622 W 168TH ST STE 260
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3720
Practice Address - Country:US
Practice Address - Phone:212-304-6172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7577363A00000X
NY028090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant