Provider Demographics
NPI:1588659387
Name:DECRISTOFARO, LOUIS T (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:LOUIS
Middle Name:T
Last Name:DECRISTOFARO
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 18029
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28814-0029
Mailing Address - Country:US
Mailing Address - Phone:828-273-8149
Mailing Address - Fax:
Practice Address - Street 1:1100 TUNNEL ROAD
Practice Address - Street 2:VA MEDICAL CENTER
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28805-2043
Practice Address - Country:US
Practice Address - Phone:828-273-8149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-18
Last Update Date:2009-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA398363A00000X
NC103541363A00000X
TN0009363A00000X
GA2669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1012656OtherNCCPA MEMBER ID
NC111717OtherNC PA CERTIFICATION NO
TN0009OtherTN PA LICENSE PHYS ASSIST
SCA398OtherSC PA LICENSE PHYS ASSIST
NC0018629OtherAAPA MEMBER ID
NC103541OtherNC PA LICENSE PHYS ASSIST
GA2669OtherGA PA LICENSE PHYS ASSIST
GAS901615668Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
NC103541OtherNC PA LICENSE PHYS ASSIST
SCS901615668Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
NCS901615668Medicare ID - Type UnspecifiedMEDICARE PROVIDER #