Healthcare Provider Details

I. General information

NPI: 1245809557
Provider Name (Legal Business Name): REGINALD CRISOSTOMO AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 TRANCAS ST
NAPA CA
94558-2906
US

IV. Provider business mailing address

1300 ETHAN WAY STE 600
SACRAMENTO CA
95825-2296
US

V. Phone/Fax

Practice location:
  • Phone: 707-252-4412
  • Fax:
Mailing address:
  • Phone: 916-482-7623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95017567
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95017567
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: