Basic Information
Provider Information | |||||||||
NPI: | 1912218280 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RAQUEPAU | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | KATHERINE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HALL | ||||||||
OtherFirstName: | AMY | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 138 PARKVIEW DR | ||||||||
Address2: |   | ||||||||
City: | AVON | ||||||||
State: | CT | ||||||||
PostalCode: | 060013453 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8609302615 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 263 FARMINGTON AVE | ||||||||
Address2: | ORTHOPAEDICS | ||||||||
City: | FARMINGTON | ||||||||
State: | CT | ||||||||
PostalCode: | 060300001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606796600 | ||||||||
FaxNumber: | 8606796604 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2010 | ||||||||
LastUpdateDate: | 12/11/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2416 | CT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 8144214-1206 | UT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.