Healthcare Provider Details

I. General information

NPI: 1467118117
Provider Name (Legal Business Name): IVANA JILLIAN CREISSTOFF PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2021
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5325 NORTHGATE DR STE 200
BETHLEHEM PA
18017-9413
US

IV. Provider business mailing address

5325 NORTHGATE DR STE 200
BETHLEHEM PA
18017-9413
US

V. Phone/Fax

Practice location:
  • Phone: 484-222-4646
  • Fax:
Mailing address:
  • Phone: 484-222-4646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA066354
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0110-008207
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: