Healthcare Provider Details

I. General information

NPI: 1669145629
Provider Name (Legal Business Name): ALI ALKABASI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 09/28/2022
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-8060
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-8082
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-2804
  • Fax: 860-679-0161
Mailing address:
  • Phone: 860-679-2804
  • Fax: 860-679-0161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number005322
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number5322
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: