Provider Demographics
NPI:1942275664
Name:MORTON, MARYALICE S (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARYALICE
Middle Name:S
Last Name:MORTON
Suffix:
Gender:F
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 1:12 MACINTOSH RD
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-5909
Mailing Address - Country:US
Mailing Address - Phone:203-866-1547
Mailing Address - Fax:
Practice Address - Street 1:24 STEVENS ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850
Practice Address - Country:US
Practice Address - Phone:203-852-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000102363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S38860Medicare UPIN