Provider Demographics
NPI:1710965397
Name:RACKLIFFE, DOREEN A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:DOREEN
Middle Name:A
Last Name:RACKLIFFE
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:255 NORTH MAIN STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010
Mailing Address - Country:US
Mailing Address - Phone:860-582-3942
Mailing Address - Fax:860-584-6529
Practice Address - Street 1:255 N MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-4972
Practice Address - Country:US
Practice Address - Phone:860-582-3942
Practice Address - Fax:860-584-6529
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000825363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS72840Medicare UPIN