Basic Information
| Provider Information | |||||||||
| NPI: | 1437790698 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BELLISSIMO | ||||||||
| FirstName: | COURTNEY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 BRADHURST AVE STE 3100N | ||||||||
| Address2: | |||||||||
| City: | HAWTHORNE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105322140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9149099018 | ||||||||
| FaxNumber: | 9149099028 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 WOODS RD | ||||||||
| Address2: | |||||||||
| City: | VALHALLA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105951530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9144936199 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2019 | ||||||||
| LastUpdateDate: | 10/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 024082 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 024082 | 01 | NY | NYS LICENSE | OTHER |