Healthcare Provider Details

I. General information

NPI: 1720743545
Provider Name (Legal Business Name): CRISTIAN PETRISOR AVASILCAI ACNPC-AG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 03/17/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2142 N COVE BLVD # 201
TOLEDO OH
43606-3895
US

IV. Provider business mailing address

1439 COLONADE CT
CANTON MI
48187-5804
US

V. Phone/Fax

Practice location:
  • Phone: 419-291-1111
  • Fax: 419-479-3253
Mailing address:
  • Phone: 248-787-3269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704300103
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704300103
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAPRN.CNP.0031011
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: