Basic Information
| Provider Information | |||||||||
| NPI: | 1295029130 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHASE | ||||||||
| FirstName: | CRISTIANA | ||||||||
| MiddleName: | COSTA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COSTA | ||||||||
| OtherFirstName: | CRISTIANA | ||||||||
| OtherMiddleName: | ABRANTES | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | DUMC BOX 3961 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2400 PRATT STREET | ||||||||
| Address2: | ABMT CLINIC | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196681002 | ||||||||
| FaxNumber: | 9196681091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2011 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OT014193 | PA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.