Provider Demographics
NPI:1831156249
Name:UTTER, ROSS G (PA)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:G
Last Name:UTTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-756-8911
Mailing Address - Fax:203-574-0548
Practice Address - Street 1:134 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2507
Practice Address - Country:US
Practice Address - Phone:203-756-8911
Practice Address - Fax:203-574-0548
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001124363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
51124OtherAIM
711609OtherCTCARE
OR0365OtherAETNA HEALTHNET
290001124CT02OtherANTHEM
A437740OtherOXFORD
P38442Medicare UPIN