Healthcare Provider Details

I. General information

NPI: 1225660277
Provider Name (Legal Business Name): MATTHEW P STRUBLE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2020
Last Update Date: 04/06/2020
Certification Date: 04/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

464 CONGRESS AVE STE 260
NEW HAVEN CT
06519-1362
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-4404
  • Fax: 203-785-4580
Mailing address:
  • Phone: 203-785-4404
  • Fax: 203-785-4580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4769
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: