Provider Demographics
NPI:1922546514
Name:DE VIVO, MARIA (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:DE VIVO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:DE VIVO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL PLZ
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-3602
Mailing Address - Country:US
Mailing Address - Phone:203-276-7022
Mailing Address - Fax:203-276-5560
Practice Address - Street 1:1 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3602
Practice Address - Country:US
Practice Address - Phone:203-276-7022
Practice Address - Fax:203-276-5560
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3770363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical