Provider Demographics
NPI:1306210216
Name:DIMEZZA, KRISTINA THERESA (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:THERESA
Last Name:DIMEZZA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 EASTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-4539
Mailing Address - Country:US
Mailing Address - Phone:631-665-1600
Mailing Address - Fax:
Practice Address - Street 1:50 NY 25-A
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4916
Practice Address - Country:US
Practice Address - Phone:631-862-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-17
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019235363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04354629Medicaid