Healthcare Provider Details

I. General information

NPI: 1871174763
Provider Name (Legal Business Name): MARK HARRISON CLOUTIER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 MIDDLE TPKE W
MANCHESTER CT
06040-3834
US

IV. Provider business mailing address

219 CLEARFIELD RD
WETHERSFIELD CT
06109-3220
US

V. Phone/Fax

Practice location:
  • Phone: 860-432-4640
  • Fax:
Mailing address:
  • Phone: 860-256-5064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5299
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: