Provider Demographics
NPI:1063572014
Name:ABASTILLAS, ANNA LIZA (APRN)
Entity type:Individual
Prefix:
First Name:ANNA LIZA
Middle Name:
Last Name:ABASTILLAS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 BREN RD E
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9664
Mailing Address - Country:US
Mailing Address - Phone:605-188-8008
Mailing Address - Fax:
Practice Address - Street 1:360 14 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489
Practice Address - Country:US
Practice Address - Phone:860-621-6759
Practice Address - Fax:860-621-0117
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002935363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004241030Medicaid
CT004241030Medicaid
Q13252Medicare UPIN