Provider Demographics
NPI:1760979637
Name:CRISOSTOMO, LAURENCE NIKKO (NP)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:NIKKO
Last Name:CRISOSTOMO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 LINCOLN BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-8096
Mailing Address - Country:US
Mailing Address - Phone:916-543-1593
Mailing Address - Fax:877-466-7829
Practice Address - Street 1:6617 TRONZANO WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-3057
Practice Address - Country:US
Practice Address - Phone:916-627-6663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95005664363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily