Provider Demographics
NPI:1881613032
Name:CRISCUOLO, TIMOTHY JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOHN
Last Name:CRISCUOLO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 NW MYHRE RD FL 3
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7662
Mailing Address - Country:US
Mailing Address - Phone:564-240-4200
Mailing Address - Fax:564-240-4299
Practice Address - Street 1:1950 NW MYHRE RD FL 3
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7662
Practice Address - Country:US
Practice Address - Phone:564-240-4200
Practice Address - Fax:564-240-4299
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002020363A00000X
WAPA60921551363AM0700X, 363A00000X
FLPA9116673363A00000X
CA60872363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2125665Medicaid
VA0110002020OtherPHYSICIAN ASST LICENSE
VA1881613032Medicaid
WA2125665Medicaid
S39703Medicare UPIN
VA007376C18Medicare ID - Type Unspecified
VA1881613032Medicaid