Healthcare Provider Details

I. General information

NPI: 1831625813
Provider Name (Legal Business Name): MAURA KATE CRISAFULLI D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 07/09/2021
Certification Date: 07/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 WESTERN AVE SUITE 102
ALBANY NY
12203-3539
US

IV. Provider business mailing address

1450 WESTERN AVE SUITE 102
ALBANY NY
12203-3539
US

V. Phone/Fax

Practice location:
  • Phone: 578-463-0050
  • Fax: 578-207-2973
Mailing address:
  • Phone: 518-463-0050
  • Fax: 578-207-2973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number309686
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number309686
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: