Provider Demographics
NPI:1720124316
Name:DIRISI, DONALD A JR (PA)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:A
Last Name:DIRISI
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 BARRA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9461
Mailing Address - Country:US
Mailing Address - Phone:207-282-5509
Mailing Address - Fax:207-294-3543
Practice Address - Street 1:46 BARRA RD STE 101
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9461
Practice Address - Country:US
Practice Address - Phone:207-282-5509
Practice Address - Fax:207-294-3543
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010518363AM0700X
MEPA1662363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03417874Medicaid
NYJ400062872/GP 70008AMedicare PIN
NYJ400062874/GP BA0017Medicare PIN
NYP15050Medicare UPIN