Basic Information
| Provider Information | |||||||||
| NPI: | 1487682803 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | REBO-MASSARA | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4700 UNION DEPOSIT RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171113774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176526605 | ||||||||
| FaxNumber: | 7176710794 | ||||||||
| Practice Location | |||||||||
| Address1: | 4700 UNION DEPOSIT RD | ||||||||
| Address2: | SUITE 140 | ||||||||
| City: | HARRISBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 171113774 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7176526605 | ||||||||
| FaxNumber: | 7176710794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | OS009880L | PA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 001811933 | 05 | PA | MEDICAID |