Healthcare Provider Details

I. General information

NPI: 1649712894
Provider Name (Legal Business Name): CORY R. DEGIACOMO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 HAYNES ST
MANCHESTER CT
06040-4131
US

IV. Provider business mailing address

71 HAYNES ST
MANCHESTER CT
06040-4131
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-1222
  • Fax:
Mailing address:
  • Phone: 860-646-1222
  • Fax: 860-688-6403

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number001079
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4461
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: