Provider Demographics
NPI:1356116057
Name:COSENZA, ANDREW (AGNP)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:COSENZA
Suffix:
Gender:M
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N MAIN STREET EXT STE 210
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2464
Mailing Address - Country:US
Mailing Address - Phone:203-627-2800
Mailing Address - Fax:
Practice Address - Street 1:821 N MAIN STREET EXT STE 210
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2464
Practice Address - Country:US
Practice Address - Phone:203-672-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-22
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT12566363LA2200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine