Provider Demographics
NPI:1225407141
Name:TETRAULT, ALEXI A (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXI
Middle Name:A
Last Name:TETRAULT
Suffix:
Gender:F
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 1:35 TALCOTTVILLE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-5261
Mailing Address - Country:US
Mailing Address - Phone:860-870-6370
Mailing Address - Fax:
Practice Address - Street 1:35 TALCOTTVILLE RD STE 1
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-5261
Practice Address - Country:US
Practice Address - Phone:860-870-6370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-21
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDI100000733133V00000X
390200000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program