Provider Demographics
NPI:1639235609
Name:CIVITILLO, TRACY G (MHS, PA-C)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:G
Last Name:CIVITILLO
Suffix:
Gender:F
Credentials:MHS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 HICKORY HILL RD
Mailing Address - Street 2:
Mailing Address - City:SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06070-2832
Mailing Address - Country:US
Mailing Address - Phone:860-306-2087
Mailing Address - Fax:
Practice Address - Street 1:500 BLUE HILLS AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1500
Practice Address - Country:US
Practice Address - Phone:860-714-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000974363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03656OtherMEDICARE
CTC03656OtherMEDICARE