Healthcare Provider Details

I. General information

NPI: 1508161969
Provider Name (Legal Business Name): MISTI TALATI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2011
Last Update Date: 12/14/2021
Certification Date: 12/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 BURNSIDE AVE 2ND FLOOR
EAST HARTFORD CT
06108-2406
US

IV. Provider business mailing address

478 BURNSIDE AVE 2ND FLOOR
EAST HARTFORD CT
06108-2406
US

V. Phone/Fax

Practice location:
  • Phone: 860-528-7161
  • Fax:
Mailing address:
  • Phone: 860-528-7161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002447
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: