Provider Demographics
NPI:1528181658
Name:DECRISTOFORO, BART JOSEPH (PA - C)
Entity Type:Individual
Prefix:MR
First Name:BART
Middle Name:JOSEPH
Last Name:DECRISTOFORO
Suffix:
Gender:M
Credentials:PA - C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:190 RIVERSIDE ST
Mailing Address - Street 2:SUITE 6B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1073
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:66 BRAMHALL ST
Practice Address - Street 2:SUITE G1
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3344
Practice Address - Country:US
Practice Address - Phone:207-662-3157
Practice Address - Fax:207-662-6434
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA-734363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400259144Medicare PIN
MEE400259149Medicare PIN