Provider Demographics
NPI:1275729949
Name:RICCIUTI, ANTHONY J JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:J
Last Name:RICCIUTI
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:95 HOCKANUM BLVD
Mailing Address - Street 2:#5225
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4099
Mailing Address - Country:US
Mailing Address - Phone:860-716-4019
Mailing Address - Fax:
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-545-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001953363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical