Provider Demographics
NPI:1659352482
Name:CAPOBIANCO, ANTHONY (PA)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:
Last Name:CAPOBIANCO
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 1:322 E MAIN ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3136
Mailing Address - Country:US
Mailing Address - Phone:203-488-7228
Mailing Address - Fax:
Practice Address - Street 1:2200 WHITNEY AVE
Practice Address - Street 2:SUITE 360
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3691
Practice Address - Country:US
Practice Address - Phone:203-281-4463
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000070363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP01275896OtherRR MEDICARE
CT008013131Medicaid
CTD400096459Medicare PIN
CT008013131Medicaid
CTP41094Medicare UPIN