Provider Demographics
NPI:1124122650
Name:CRISCUOLO BECK, AIMEE J (PA)
Entity type:Individual
Prefix:
First Name:AIMEE
Middle Name:J
Last Name:CRISCUOLO BECK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:AIMEE
Other - Middle Name:
Other - Last Name:CRISCUOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:420 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4747
Mailing Address - Country:US
Mailing Address - Phone:860-626-2010
Mailing Address - Fax:
Practice Address - Street 1:481 GOLD STAR HWY STE 100
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6702
Practice Address - Country:US
Practice Address - Phone:860-446-8858
Practice Address - Fax:860-405-2140
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000925363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000925OtherCONNECTICARE
CT290000925CT01OtherANTHEM BC/BS
CT290000925CT01OtherANTHEM BC/BS