Provider Demographics
NPI:1174509095
Name:FEDERER, ERIC ANTON (APRN)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:ANTON
Last Name:FEDERER
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 BELL HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06793
Mailing Address - Country:US
Mailing Address - Phone:860-868-2625
Mailing Address - Fax:
Practice Address - Street 1:538 LITCHFIELD ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6669
Practice Address - Country:US
Practice Address - Phone:860-489-5068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003074363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004243838Medicaid