Active NPI
Jody Vicencio Crisostomo, PAC
- Physician Assistant
- Jacksonville, FL
National Provider Identifier
1700829033
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- PA1911
- Practice address
- 4243 Sunbeam Rd Ste 6
Jacksonville, FL 32257-8975 - Phone
- (904) 737-1838
- Fax
- (904) 737-1206
- NPI assigned
- Jun 14, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | PA1911 | FL | Primary |
Addresses
Primary practice location
4243 Sunbeam Rd Ste 6
Jacksonville, FL 32257-8975
Mailing address
PO Box 57970
Jacksonville, FL 32241-7970
Phone (904) 737-1838
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| PA1911 | FL | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1150243200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1207872000000",
"number": "1700829033",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 57970",
"city": "JACKSONVILLE",
"state": "FL",
"postal_code": "322417970",
"telephone_number": "904-737-1838"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4243 SUNBEAM RD STE 6",
"city": "JACKSONVILLE",
"state": "FL",
"postal_code": "322578975",
"telephone_number": "904-737-1838",
"fax_number": "904-737-1206"
}
],
"practiceLocations": [],
"basic": {
"last_name": "CRISOSTOMO",
"first_name": "JODY",
"middle_name": "VICENCIO",
"name_prefix": "Mr.",
"credential": "PAC",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-06-14",
"last_updated": "2008-04-11",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "FL",
"license": "PA1911",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Jacksonville, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 11, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.