Provider Demographics
NPI:1831625813
Name:CRISAFULLI, MAURA KATE (DO)
Entity type:Individual
Prefix:
First Name:MAURA KATE
Middle Name:
Last Name:CRISAFULLI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 WESTERN AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-3539
Mailing Address - Country:US
Mailing Address - Phone:518-463-0050
Mailing Address - Fax:578-207-2973
Practice Address - Street 1:1450 WESTERN AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-3539
Practice Address - Country:US
Practice Address - Phone:578-463-0050
Practice Address - Fax:578-207-2973
Is Sole Proprietor?:No
Enumeration Date:2017-05-11
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309686390200000X, 207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program