Healthcare Provider Details

I. General information

NPI: 1295768166
Provider Name (Legal Business Name): ELIZABETH WOOTTON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 01/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 HOWARD AVENUE YALE NEW HAVEN HOSPITAL
NEW HAVEN CT
06519
US

IV. Provider business mailing address

15 MARION CT
NORTH HAVEN CT
06473-2016
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-3561
  • Fax: 203-785-6815
Mailing address:
  • Phone: 203-859-5333
  • Fax: 203-785-6815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000128
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: