Provider Demographics
NPI:1104228022
Name:TAGLIAVINI, CHRISTOPHER (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:TAGLIAVINI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:SUFFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06078-3006
Mailing Address - Country:US
Mailing Address - Phone:860-584-8291
Mailing Address - Fax:860-584-8354
Practice Address - Street 1:22 PINE ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-6948
Practice Address - Country:US
Practice Address - Phone:860-584-8291
Practice Address - Fax:860-584-8354
Is Sole Proprietor?:No
Enumeration Date:2014-09-23
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3201363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical