Healthcare Provider Details

I. General information

NPI: 1124122650
Provider Name (Legal Business Name): AIMEE J CRISCUOLO BECK P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AIMEE CRISCUOLO PA

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 GOLD STAR HWY STE 100
GROTON CT
06340-6702
US

IV. Provider business mailing address

420 SAYBROOK RD
MIDDLETOWN CT
06457-4747
US

V. Phone/Fax

Practice location:
  • Phone: 860-446-8858
  • Fax: 860-405-2140
Mailing address:
  • Phone: 860-626-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000925
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: