Provider Demographics
NPI:1154516672
Name:LETKO, MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:LETKO
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 1:1389 W MAIN ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3104
Mailing Address - Country:US
Mailing Address - Phone:203-573-9418
Mailing Address - Fax:203-573-8523
Practice Address - Street 1:1389 W MAIN STREET
Practice Address - Street 2:SUITE 120
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3104
Practice Address - Country:US
Practice Address - Phone:203-573-9418
Practice Address - Fax:203-573-8523
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001168939Medicaid