=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699588111
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSHUA V CRISANO PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2025
-----------------------------------------------------
Last Update Date | 03/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3259 CATLIN AVE
-----------------------------------------------------
City | QUANTICO
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22134-5109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-784-1651
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13126 ADAMS ST
-----------------------------------------------------
City | QUANTICO
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22134-4211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-342-1157
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2306606054
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------