Provider Demographics
NPI:1477528735
Name:SOUTHALL, ANNE DELANCEY (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ANNE
Middle Name:DELANCEY
Last Name:SOUTHALL
Suffix:
Gender:F
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 1:24 LOWER TRINITY PASS RD
Mailing Address - Street 2:
Mailing Address - City:POUND RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:10576-2121
Mailing Address - Country:US
Mailing Address - Phone:914-764-0733
Mailing Address - Fax:
Practice Address - Street 1:24 STEVENS ST
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3852
Practice Address - Country:US
Practice Address - Phone:203-852-2000
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001526363A00000X
MEPA761363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P47055Medicare UPIN