Provider Demographics
NPI:1003206434
Name:OCCHIBOI, EMIL (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:EMIL
Middle Name:
Last Name:OCCHIBOI
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:EJ
Other - Middle Name:
Other - Last Name:OCCHIBOI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:82 NEW PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH FRANKLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06254-1807
Mailing Address - Country:US
Mailing Address - Phone:860-889-7345
Mailing Address - Fax:
Practice Address - Street 1:82 NEW PARK AVE
Practice Address - Street 2:
Practice Address - City:NORTH FRANKLIN
Practice Address - State:CT
Practice Address - Zip Code:06254-1807
Practice Address - Country:US
Practice Address - Phone:860-889-7345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08548363A00000X
CT23.004688363AS0400X
CT0009072255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNN5848AMedicaid