MEDICARE: MR. DOMINICK C. MARICONDA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	000794	CT

General Provider Information

NPI Number	:	1790702462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DOMINICK C. MARICONDA PA-C

Provider Business Mailing Address
First Line	:	11 E GATE RD
Second Line	:
City	:	GUILFORD
State	:	CT
Zip	:	06437-2263
Country	:	US
Telephone Number	:	203-458-1634
Fax Number	:

Provider Business Practice Location Address
First Line	:	20 YORK ST
Second Line	:	CB 2045
City	:	NEW HAVEN
State	:	CT
Zip	:	06504-8900
Country	:	US
Telephone Number	:	203-688-8993
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	07/08/2007

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