Provider Demographics
NPI:1649364878
Name:RODRIGUEZ MERTURI, ANNETTE (PA)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:RODRIGUEZ MERTURI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 BARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06608-2409
Mailing Address - Country:US
Mailing Address - Phone:203-333-3030
Mailing Address - Fax:
Practice Address - Street 1:471 BARNUM AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06608-2409
Practice Address - Country:US
Practice Address - Phone:203-333-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001094363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004234788Medicaid