Basic Information
Provider Information | |||||||||
NPI: | 1912920695 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DELUCIA | ||||||||
FirstName: | KATHY | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 305 BLACK ROCK TPKE | ||||||||
Address2: | OSG | ||||||||
City: | FAIRFIELD | ||||||||
State: | CT | ||||||||
PostalCode: | 068255508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033372600 | ||||||||
FaxNumber: | 2033372666 | ||||||||
Practice Location | |||||||||
Address1: | 305 BLACK ROCK TPKE | ||||||||
Address2: |   | ||||||||
City: | FAIRFIELD | ||||||||
State: | CT | ||||||||
PostalCode: | 068255508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033372600 | ||||||||
FaxNumber: | 2033372666 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/25/2006 | ||||||||
LastUpdateDate: | 03/30/2017 | ||||||||
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 | 000130 | CT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 290000130CT01 | 01 | CT | ANTHEM BC/BS | OTHER | P3511340 | 01 | CT | OXFORD HEALTH PLANS | OTHER | TIN | 01 |   | CORVEL | OTHER | TIN | 01 |   | BERLKEY ADMINISTRATORS | OTHER | TIN | 01 |   | MULTI PLAN | OTHER | TIN | 01 |   | PIONEER | OTHER | 9301 | 01 | CT | CONNECTICARE | OTHER | 2V6005 | 01 | CT | HEALTH NET | OTHER | TIN | 01 |   | INTEGRATED HEALTH PLAN | OTHER |