Healthcare Provider Details

I. General information

NPI: 1265803738
Provider Name (Legal Business Name): ALEXANDRA R. VITALE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRA VITALE PA-C

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 RIVERSIDE AVE
BRISTOL CT
06010
US

IV. Provider business mailing address

2408 WHITNEY AVE
HAMDEN CT
06518-3209
US

V. Phone/Fax

Practice location:
  • Phone: 860-585-3333
  • Fax:
Mailing address:
  • Phone: 203-626-0160
  • Fax: 203-294-6734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3455
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3455
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3455
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: