Provider Demographics
NPI:1457847790
Name:MIGLIETTA, THOMAS CROWLEY (PA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:CROWLEY
Last Name:MIGLIETTA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MAYNARD ST
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-1129
Mailing Address - Country:US
Mailing Address - Phone:203-470-6446
Mailing Address - Fax:
Practice Address - Street 1:100 KENYON AVE
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879-4216
Practice Address - Country:US
Practice Address - Phone:401-782-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
RIPA01444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1457847790Medicaid