Provider Demographics
NPI:1700372356
Name:DACOSTA, ANNE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ANNE
Middle Name:ELIZABETH
Last Name:DACOSTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNE
Other - Middle Name:ELIZABETH
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:47 SUNSET LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:CT
Mailing Address - Zip Code:06754-1701
Mailing Address - Country:US
Mailing Address - Phone:860-866-6938
Mailing Address - Fax:
Practice Address - Street 1:67 SLADES FERRY AVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:MA
Practice Address - Zip Code:02726-1220
Practice Address - Country:US
Practice Address - Phone:508-678-5633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4157363A00000X
MAPA7680363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant