Provider Demographics
NPI:1104494368
Name:RAINES, ALYSSA CHRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:CHRISTINE
Last Name:RAINES
Suffix:
Gender:F
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 1:9 OLD ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-5505
Mailing Address - Country:US
Mailing Address - Phone:516-512-1938
Mailing Address - Fax:
Practice Address - Street 1:1 AUDUBON ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6433
Practice Address - Country:US
Practice Address - Phone:203-562-7662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-15
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT5320208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program