Provider Demographics
NPI:1912218280
Name:RAQUEPAU, AMY KATHERINE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:KATHERINE
Last Name:RAQUEPAU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:K
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:138 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3453
Mailing Address - Country:US
Mailing Address - Phone:860-930-2615
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:ORTHOPAEDICS
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-6600
Practice Address - Fax:860-679-6604
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2416363A00000X
UT8144214-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant