Provider Demographics
NPI:1194807180
Name:MOTTA, JAVIER (PA)
Entity type:Individual
Prefix:
First Name:JAVIER
Middle Name:
Last Name:MOTTA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 SAMSON ROCK DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-3018
Mailing Address - Country:US
Mailing Address - Phone:203-318-8000
Mailing Address - Fax:
Practice Address - Street 1:146 SAMSON ROCK DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3018
Practice Address - Country:US
Practice Address - Phone:203-318-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP53986363A00000X
NJ25MP00195700363A00000X
CT3176363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP53986OtherLICENSE
NJ178997VGNMedicare PIN