Provider Demographics
NPI:1790702462
Name:MARICONDA, DOMINICK C (PA-C)
Entity Type:Individual
Prefix:MR
First Name:DOMINICK
Middle Name:C
Last Name:MARICONDA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E GATE RD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2263
Mailing Address - Country:US
Mailing Address - Phone:203-458-1634
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:CB 2045
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06504-8900
Practice Address - Country:US
Practice Address - Phone:203-688-8993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant