Healthcare Provider Details

I. General information

NPI: 1972022135
Provider Name (Legal Business Name): COLLEEN BOOTH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2017
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 HAYNES ST
MANCHESTER CT
06040-4131
US

IV. Provider business mailing address

104 PITKIN ST
MANCHESTER CT
06040-4456
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-1222
  • Fax:
Mailing address:
  • Phone: 860-685-0816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3964
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3964
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: