Provider Demographics
NPI:1376645382
Name:DECORA, MARK E (PA C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:E
Last Name:DECORA
Suffix:
Gender:M
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 1:112 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2737
Mailing Address - Country:US
Mailing Address - Phone:860-425-8701
Mailing Address - Fax:860-425-8707
Practice Address - Street 1:88 NEW LONDON TPKE
Practice Address - Street 2:
Practice Address - City:UNCASVILL
Practice Address - State:CT
Practice Address - Zip Code:06382-0000
Practice Address - Country:US
Practice Address - Phone:860-848-1297
Practice Address - Fax:860-848-2487
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000449363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970000303Medicare PIN
S55219Medicare UPIN