Provider Demographics
NPI:1003195785
Name:WINTER, ELISE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELISE
Middle Name:
Last Name:WINTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 HARTFORD TPKE
Mailing Address - Street 2:SUITE M
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-5037
Mailing Address - Country:US
Mailing Address - Phone:860-872-8321
Mailing Address - Fax:860-875-6271
Practice Address - Street 1:520 HARTFORD TPKE
Practice Address - Street 2:SUITE M
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5037
Practice Address - Country:US
Practice Address - Phone:860-872-8321
Practice Address - Fax:860-875-6271
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT363AS0400X
CT002622363A00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine