Provider Demographics
NPI:1265468060
Name:BELLAVIA, TANYA L (PA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:BELLAVIA
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 1:916 SPRING MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7198
Mailing Address - Country:US
Mailing Address - Phone:716-861-6268
Mailing Address - Fax:
Practice Address - Street 1:2400 PRATT ST STE 1000
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3976
Practice Address - Country:US
Practice Address - Phone:919-684-8964
Practice Address - Fax:919-681-1090
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8208363A00000X
NY007505-1363A00000X
NC0010-13648363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00026531701OtherUNIVERA HEALTHCARE
NY9511873OtherINDEPENDENT HEALTH
NYP14503Medicare UPIN