Healthcare Provider Details

I. General information

NPI: 1548218191
Provider Name (Legal Business Name): CARRIE A DOHERTY P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE A LUX P.A.

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 BATTLE ST
SOMERS CT
06071-1629
US

IV. Provider business mailing address

24 BATTLE ST
SOMERS CT
06071-1629
US

V. Phone/Fax

Practice location:
  • Phone: 860-749-8887
  • Fax: 860-749-7421
Mailing address:
  • Phone: 860-749-8887
  • Fax: 860-749-7421

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001263
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: