Provider Demographics
NPI:1114228251
Name:CAMPBELL, ELISABETH MARIE (PA)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:MARIE
Last Name:CAMPBELL
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 1:114 WOODLAND ST
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1208
Mailing Address - Country:US
Mailing Address - Phone:860-714-5237
Mailing Address - Fax:
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:DEPTARTMENT OF SURGERY
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-5237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105547363A00000X
CT3094363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant