Provider Demographics
NPI:1912920695
Name:DELUCIA, KATHY E (PA)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:E
Last Name:DELUCIA
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 1:305 BLACK ROCK TPKE
Mailing Address - Street 2:OSG
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-5508
Mailing Address - Country:US
Mailing Address - Phone:203-337-2600
Mailing Address - Fax:203-337-2666
Practice Address - Street 1:305 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-5508
Practice Address - Country:US
Practice Address - Phone:203-337-2600
Practice Address - Fax:203-337-2666
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT290000130CT01OtherANTHEM BC/BS
CTP3511340OtherOXFORD HEALTH PLANS
TINOtherCORVEL
TINOtherBERLKEY ADMINISTRATORS
TINOtherMULTI PLAN
TINOtherPIONEER
CT9301OtherCONNECTICARE
CT2V6005OtherHEALTH NET
TINOtherINTEGRATED HEALTH PLAN
CT290000130CT01OtherANTHEM BC/BS
TINOtherINTEGRATED HEALTH PLAN