Healthcare Provider Details

I. General information

NPI: 1912334590
Provider Name (Legal Business Name): AMANDA M HARTE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 09/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 LEWIS AVE
MERIDEN CT
06451-2101
US

IV. Provider business mailing address

103 HIDDEN VALLEY RD
GROTON MA
01450-2234
US

V. Phone/Fax

Practice location:
  • Phone: 203-694-8200
  • Fax:
Mailing address:
  • Phone: 978-448-9904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2990
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: