Healthcare Provider Details

I. General information

NPI: 1588621916
Provider Name (Legal Business Name): MICHAEL BELLAS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 08/13/2007
Certification Date:
Deactivation Date: 07/17/2007
Reactivation Date: 08/13/2007

III. Provider practice location address

1397 WEIMER RD
TAOS NM
87571-2199
US

IV. Provider business mailing address

PO BOX DD
TAOS NM
87571-2199
US

V. Phone/Fax

Practice location:
  • Phone: 505-758-8883
  • Fax: 505-751-5718
Mailing address:
  • Phone: 505-758-8883
  • Fax: 505-751-5718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: