Provider Demographics
NPI:1346316502
Name:BUCCIGROSS, HEATHER ANN (PA C)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:ANN
Last Name:BUCCIGROSS
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:MS
Other - First Name:HEATHER
Other - Middle Name:ANN
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:1563 POST ROAD EAST
Mailing Address - Street 2:
Mailing Address - City:WESTPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06880
Mailing Address - Country:US
Mailing Address - Phone:203-319-3939
Mailing Address - Fax:203-319-3966
Practice Address - Street 1:1563 POST ROAD EAST
Practice Address - Street 2:
Practice Address - City:WESTPORT
Practice Address - State:CT
Practice Address - Zip Code:06880
Practice Address - Country:US
Practice Address - Phone:203-319-3939
Practice Address - Fax:203-319-3966
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000681363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical