Healthcare Provider Details

I. General information

NPI: 1952821431
Provider Name (Legal Business Name): ANDREW J DECUSATI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2017
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEYMOUR ST
HARTFORD CT
06106-5501
US

IV. Provider business mailing address

1290 SILAS DEANE HWY HARTFORD HEALTHCARE-CVO
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-278-0070
  • Fax: 860-522-6081
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number00000
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3893
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: