Provider Demographics
NPI:1477838324
Name:BECK, ALICIA D (PA)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:D
Last Name:BECK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 BOSTON POST RD STE 10
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1554
Mailing Address - Country:US
Mailing Address - Phone:860-388-9799
Mailing Address - Fax:860-388-6626
Practice Address - Street 1:455 BOSTON POST RD STE 10
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-1554
Practice Address - Country:US
Practice Address - Phone:860-388-9799
Practice Address - Fax:860-388-6626
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002637363AM0700X
RIPA00662363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2367OtherLICENSE
RIPA00662OtherLICENSE
CT002637OtherLICENSE