Provider Demographics
NPI:1346717352
Name:MASTROGIACOMO, KATELYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:MASTROGIACOMO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:MORICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:635 ASHLEY CT
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3246
Mailing Address - Country:US
Mailing Address - Phone:203-980-1836
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4201
Practice Address - Country:US
Practice Address - Phone:203-576-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-29
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4397363AS0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program