Basic Information
| Provider Information | |||||||||
| NPI: | 1720167950 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISALIDA | ||||||||
| FirstName: | TERA | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3055 N RED MTN UNIT 220 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852071059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082015111 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1006 E GUADALUPE RD | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852833047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808384296 | ||||||||
| FaxNumber: | 4808201275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 07/13/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-530 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3834 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 341903 | 05 | AZ | MEDICAID |