Provider Demographics
NPI:1306816327
Name:CRISOLOGO, FLOR DE MARIA (PA)
Entity Type:Individual
Prefix:MISS
First Name:FLOR
Middle Name:DE MARIA
Last Name:CRISOLOGO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 NE 95TH ST
Mailing Address - Street 2:SUITE 9
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33138-2745
Mailing Address - Country:US
Mailing Address - Phone:305-751-5454
Mailing Address - Fax:305-751-1977
Practice Address - Street 1:209 NE 95TH ST
Practice Address - Street 2:SUITE 9
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33138-2745
Practice Address - Country:US
Practice Address - Phone:305-751-5454
Practice Address - Fax:305-751-1977
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN2114402163W00000X
FLPA9100393363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290990100Medicaid
FL290990100Medicaid