Provider Demographics
NPI:1457323875
Name:CRISAFULLI, TERESA K (PAC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:K
Last Name:CRISAFULLI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:
Other - Last Name:KANJUPARAMBAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 758900
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21275-8900
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:640 S STATE ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-3530
Practice Address - Country:US
Practice Address - Phone:410-398-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003050363A00000X
DEC50000490363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S91221Medicare UPIN
DE020423D18Medicare PIN