Provider Demographics
NPI:1245753656
Name:CRISOSTOMO, RICHARD (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:CRISOSTOMO
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3505 E MERIDIAN PARK LOOP STE 200
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7242
Mailing Address - Country:US
Mailing Address - Phone:079-357-4400
Mailing Address - Fax:079-357-4410
Practice Address - Street 1:3505 E MERIDIAN PARK LOOP STE 200
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7242
Practice Address - Country:US
Practice Address - Phone:079-357-4400
Practice Address - Fax:907-357-4410
Is Sole Proprietor?:No
Enumeration Date:2017-07-18
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVTAPRN701646363LP0808X
NVAPRN002619363LP0808X
AK132337363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health