Provider Demographics
NPI:1528006038
Name:RAU, GREGORY JARVIS (PA)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:JARVIS
Last Name:RAU
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3 PATRICIA LN
Mailing Address - Street 2:
Mailing Address - City:CROMWELL
Mailing Address - State:CT
Mailing Address - Zip Code:06416-2432
Mailing Address - Country:US
Mailing Address - Phone:203-865-6143
Mailing Address - Fax:
Practice Address - Street 1:134 PARK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5409
Practice Address - Country:US
Practice Address - Phone:203-865-6143
Practice Address - Fax:203-772-1265
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001251363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970001137Medicare ID - Type Unspecified
CTP70652Medicare UPIN