Provider Demographics
NPI:1033484241
Name:MITTAL, JYOTI (PA)
Entity Type:Individual
Prefix:
First Name:JYOTI
Middle Name:
Last Name:MITTAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:JUDY
Other - Middle Name:
Other - Last Name:MITTAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:515 MIDDLE TPKE W
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-3816
Mailing Address - Country:US
Mailing Address - Phone:860-533-4176
Mailing Address - Fax:
Practice Address - Street 1:515 MIDDLE TPKE W
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3816
Practice Address - Country:US
Practice Address - Phone:860-533-4176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-21
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2965363A00000X
CT002965363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA248503Medicare UPIN