Provider Demographics
NPI:1730567611
Name:REBOLLO, ALANA C (PA)
Entity type:Individual
Prefix:
First Name:ALANA
Middle Name:C
Last Name:REBOLLO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104
Mailing Address - Country:US
Mailing Address - Phone:413-739-5676
Mailing Address - Fax:413-733-5860
Practice Address - Street 1:85 POHEGANUT DR
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-3252
Practice Address - Country:US
Practice Address - Phone:860-448-6303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-12
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003299363A00000X
MDC5760363A00000X
MDC00A5760363A00000X
CT3299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant