Provider Demographics
NPI:1497059273
Name:CRISOSTOMO, ASAYA ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ASAYA
Middle Name:ANN
Last Name:CRISOSTOMO
Suffix:
Gender:F
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 1:2101 PARK CENTER DR STE 130
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-7611
Mailing Address - Country:US
Mailing Address - Phone:407-298-6950
Mailing Address - Fax:407-578-2354
Practice Address - Street 1:2101 PARK CENTER DR STE 130
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-7611
Practice Address - Country:US
Practice Address - Phone:407-298-6950
Practice Address - Fax:407-578-2354
Is Sole Proprietor?:No
Enumeration Date:2011-01-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9114297363A00000X, 363AM0700X
CA54208363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP1019777OtherFREEDOM
FLY0J2WOtherBCBS OF FL
FL1225266OtherWELLCARE
FL009560400Medicaid
FL5569125OtherCIGNA
FL7513951OtherAETNA
FLP01214789OtherRAILROAD MCR
FLP958302OtherOPTIMUM
FLU4198YMedicare PIN