Provider Demographics
NPI:1720081110
Name:DESTEFANO, GREGORY S (APRN)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:S
Last Name:DESTEFANO
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2129
Mailing Address - Country:US
Mailing Address - Phone:203-645-5053
Mailing Address - Fax:
Practice Address - Street 1:NP RESOURCES, LLC
Practice Address - Street 2:SIX CORPORATE DRIVE, SUITE 420
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484
Practice Address - Country:US
Practice Address - Phone:203-925-9600
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002291363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP16493Medicare UPIN