Provider Demographics
NPI:1992131676
Name:MICELI, SARA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:MARIE
Last Name:MICELI
Suffix:
Gender:F
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 1:166 WATERBURY RD STE 104
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1246
Mailing Address - Country:US
Mailing Address - Phone:203-756-6422
Mailing Address - Fax:
Practice Address - Street 1:166 WATERBURY RD STE 104
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712-1246
Practice Address - Country:US
Practice Address - Phone:203-756-6422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2983363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant