Provider Demographics
NPI:1154622553
Name:DIZON, TABOR DAVID (PA-C)
Entity type:Individual
Prefix:
First Name:TABOR
Middle Name:DAVID
Last Name:DIZON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:TABOR
Other - Middle Name:DAVID
Other - Last Name:MURPHY-DIZON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:P.O. BOX 415933
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5933
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR STREET
Practice Address - Street 2:HARTFORD HOSPITAL CRITICAL CARE MEDICINE
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-5037
Practice Address - Country:US
Practice Address - Phone:860-545-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002519363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003025194Medicaid