Provider Demographics
NPI:1285793935
Name:FOTHERGILL, KEVA C (PA)
Entity type:Individual
Prefix:
First Name:KEVA
Middle Name:C
Last Name:FOTHERGILL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-442-7027
Mailing Address - Fax:860-444-0074
Practice Address - Street 1:26 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-3408
Practice Address - Country:US
Practice Address - Phone:860-889-7321
Practice Address - Fax:860-444-7401
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1285793935Medicaid
CT1285793935Medicaid