Provider Demographics
NPI:1649712894
Name:DEGIACOMO, CORY R (PA-C)
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:R
Last Name:DEGIACOMO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 POQUONOCK AVE
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-2429
Mailing Address - Country:US
Mailing Address - Phone:860-688-5774
Mailing Address - Fax:860-688-6403
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-688-5774
Practice Address - Fax:860-688-6403
Is Sole Proprietor?:No
Enumeration Date:2016-11-04
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT4461363A00000X
CT0010792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer