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General NPI Number Information
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NPI Number | 1790702462
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Entity Type | Individual
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Provider Name | DOMINICK C. MARICONDA PA-C
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Gender | Male
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Dates
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Enumeration Date | 07/17/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 20 YORK ST CB 2045
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City | NEW HAVEN
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State | CT
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Zip | 06504-8900
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Country | US
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Telephone | 203-688-8993
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Fax |
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Provider Business Mailing Address
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Address Line | 11 E GATE RD
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City | GUILFORD
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State | CT
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Zip | 06437-2263
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Country | US
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Telephone | 203-458-1634
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 000794
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License Number State | CT
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