Provider Demographics
NPI:1245809557
Name:CRISOSTOMO, REGINALD (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:
Last Name:CRISOSTOMO
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 ETHAN WAY STE 600
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2296
Mailing Address - Country:US
Mailing Address - Phone:916-482-7623
Mailing Address - Fax:
Practice Address - Street 1:1000 TRANCAS ST
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2906
Practice Address - Country:US
Practice Address - Phone:707-252-4412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017567163W00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0000Medicaid