Provider Demographics
NPI:1588621916
Name:BELLAS, MICHAEL (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BELLAS
Suffix:
Gender:M
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:PO BOX DD
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-2199
Mailing Address - Country:US
Mailing Address - Phone:505-758-8883
Mailing Address - Fax:505-751-5718
Practice Address - Street 1:1397 WEIMER RD
Practice Address - Street 2:
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-2199
Practice Address - Country:US
Practice Address - Phone:505-758-8883
Practice Address - Fax:505-751-5718
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2007-08-13
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-13
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMH5538Medicaid
343504803Medicare PIN
Q35901Medicare UPIN