Healthcare Provider Details

I. General information

NPI: 1932684974
Provider Name (Legal Business Name): KAITLYN ZUGIBE PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 MEMORIAL RD STE 508
WEST HARTFORD CT
06107-4233
US

IV. Provider business mailing address

65 MEMORIAL RD STE 508
WEST HARTFORD CT
06107-4233
US

V. Phone/Fax

Practice location:
  • Phone: 860-696-2925
  • Fax:
Mailing address:
  • Phone: 860-696-2925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number022600
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00578000
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4257
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: