1104829720 NPI number — RICHARD V PANETTA APRN

Table of content: RICHARD V PANETTA APRN (NPI 1104829720)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104829720 NPI number — RICHARD V PANETTA APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANETTA
Provider First Name:
RICHARD
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104829720
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/01/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
95 MARNEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLEBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06762-2024
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-758-8350
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NP RESOURCES, LLC.
Provider Second Line Business Practice Location Address:
SIX COPRPORATE DRIVE, SUITE 420
Provider Business Practice Location Address City Name:
SHELTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06484
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-925-9600
Provider Business Practice Location Address Fax Number:
203-926-0594
Provider Enumeration Date:
05/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  002011 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: 002011 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004195865 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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