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General NPI Number Information
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NPI Number | 1891275731
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Entity Type | Individual
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Provider Name | DEMETRA VENANCIO PA-C
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Gender | Female
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Dates
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Enumeration Date | 08/20/2018
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Last Update Date | 11/04/2022
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Provider Practice Location Address
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Address Line | 1055 POST RD
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City | FAIRFIELD
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State | CT
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Zip | 06824-6019
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Country | US
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Telephone | 203-259-3440
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Fax |
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Provider Business Mailing Address
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Address Line | 640 CENTRE ST
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City | JAMAICA PLAIN
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State | MA
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Zip | 02130-2555
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Country | US
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Telephone |
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA6723
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 5815
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License Number State | CT
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