Provider Demographics
NPI:1871174763
Name:CLOUTIER, MARK HARRISON (PA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:HARRISON
Last Name:CLOUTIER
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 1:219 CLEARFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-3220
Mailing Address - Country:US
Mailing Address - Phone:860-256-5064
Mailing Address - Fax:
Practice Address - Street 1:277 MIDDLE TPKE W
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3834
Practice Address - Country:US
Practice Address - Phone:860-432-4640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT5299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program