Healthcare Provider Details

I. General information

NPI: 1750638763
Provider Name (Legal Business Name): ADRIAN ROY PUNZALAN CRISOSTOMO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2012
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 SWIFT BLVD
RICHLAND WA
99352-3514
US

IV. Provider business mailing address

550 GAGE BLVD STE 101
RICHLAND WA
99352-9532
US

V. Phone/Fax

Practice location:
  • Phone: 509-946-4611
  • Fax:
Mailing address:
  • Phone: 509-942-3627
  • Fax: 509-627-2983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60445797
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD60445797
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: