Provider Demographics
NPI:1144755067
Name:GRETEN-HARRISON, BECKET L (PA-C)
Entity Type:Individual
Prefix:
First Name:BECKET
Middle Name:L
Last Name:GRETEN-HARRISON
Suffix:
Gender:M
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 1:499 AMITY RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-1603
Mailing Address - Country:US
Mailing Address - Phone:203-886-9307
Mailing Address - Fax:
Practice Address - Street 1:499 AMITY RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:CT
Practice Address - Zip Code:06525-1603
Practice Address - Country:US
Practice Address - Phone:203-886-9307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3818363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant