Provider Demographics
NPI:1194109652
Name:BELLASSAI, KRISTA (PA)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:BELLASSAI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 NORTHPORT AVE
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-6009
Mailing Address - Country:US
Mailing Address - Phone:585-338-2500
Mailing Address - Fax:
Practice Address - Street 1:118 NORTHPORT AVE
Practice Address - Street 2:
Practice Address - City:BELFAST
Practice Address - State:ME
Practice Address - Zip Code:04915-6009
Practice Address - Country:US
Practice Address - Phone:207-338-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018739363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04247054Medicaid
NYJ400244589-GRPBA0017Medicare PIN
NYJ400244586-GRP70008AMedicare PIN