Provider Demographics
NPI:1043403868
Name:LIDESTRI, GINA F (PA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:F
Last Name:LIDESTRI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:F
Other - Last Name:MANGARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:41 BREWSTER RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5161
Mailing Address - Country:US
Mailing Address - Phone:860-585-3313
Mailing Address - Fax:
Practice Address - Street 1:41 BREWSTER RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5161
Practice Address - Country:US
Practice Address - Phone:860-585-3313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001942363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant