Provider Demographics
NPI:1417055914
Name:VAZQUEZ-VALICEK, AMELIA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMELIA
Middle Name:
Last Name:VAZQUEZ-VALICEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMELIA
Other - Middle Name:KATHLEEN
Other - Last Name:VAZQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:365 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4700
Mailing Address - Country:US
Mailing Address - Phone:860-442-0711
Mailing Address - Fax:860-271-4224
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:860-271-4224
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000419363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
06-0646704OtherTRICARE
CT4014679Medicaid
CT4024972Medicaid
CT4024972Medicaid