Provider Demographics
NPI:1720167950
Name:CRISALIDA, TERA (PA)
Entity Type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:CRISALIDA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3055 N RED MTN UNIT 220
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-1059
Mailing Address - Country:US
Mailing Address - Phone:208-201-5111
Mailing Address - Fax:
Practice Address - Street 1:1006 E GUADALUPE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-3047
Practice Address - Country:US
Practice Address - Phone:480-838-4296
Practice Address - Fax:480-820-1275
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-530363A00000X
AZ3834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ341903Medicaid
AZZ122727Medicare PIN
IDS90253Medicare UPIN