Provider Demographics
NPI:1801904610
Name:BELLOMO, RISHA LISA (PA)
Entity type:Individual
Prefix:
First Name:RISHA
Middle Name:LISA
Last Name:BELLOMO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RISHA
Other - Middle Name:LISA
Other - Last Name:KING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:15835 TURKEY ISLAND CIR
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-9481
Mailing Address - Country:US
Mailing Address - Phone:407-766-3429
Mailing Address - Fax:
Practice Address - Street 1:2504 S ALAFAYA TRL STE 310
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7977
Practice Address - Country:US
Practice Address - Phone:407-505-9951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290445400Medicaid
FLE7816ZMedicare ID - Type Unspecified
FL290445400Medicaid