Provider Demographics
NPI:1770347619
Name:CRISAFULLI, ANTHONY TANNER
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:TANNER
Last Name:CRISAFULLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 WELLHAVEN CIR APT 1026
Mailing Address - Street 2:
Mailing Address - City:GARRISON
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5012
Mailing Address - Country:US
Mailing Address - Phone:240-688-9264
Mailing Address - Fax:
Practice Address - Street 1:5009 HONEYGO CENTER DR STE 209
Practice Address - Street 2:
Practice Address - City:PERRY HALL
Practice Address - State:MD
Practice Address - Zip Code:21128-9842
Practice Address - Country:US
Practice Address - Phone:443-725-2150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program