Provider Demographics
NPI:1962829101
Name:CRISCUOLO, GREGORY RICHARD JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:RICHARD
Last Name:CRISCUOLO
Suffix:JR
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:360 BLOOMFIELD AVE
Mailing Address - Street 2:STE 209
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2700
Mailing Address - Country:US
Mailing Address - Phone:860-258-3470
Mailing Address - Fax:
Practice Address - Street 1:1 LAKE ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1396
Practice Address - Country:US
Practice Address - Phone:860-258-3470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-26
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT3047363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant