Provider Demographics
NPI:1063554426
Name:BALESTRIERI, JAY A (NP)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:A
Last Name:BALESTRIERI
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 N BLAZING TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO WEST
Mailing Address - State:CO
Mailing Address - Zip Code:81007-3934
Mailing Address - Country:US
Mailing Address - Phone:719-251-2071
Mailing Address - Fax:
Practice Address - Street 1:400 W 17TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2649
Practice Address - Country:US
Practice Address - Phone:719-296-6872
Practice Address - Fax:719-583-0688
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO109032363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO69325561Medicaid
C808365Medicare PIN