Provider Demographics
NPI:1366952863
Name:PELLETIER, KEITH JOSEPH (MBA, MHS, CCP, LP)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:JOSEPH
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:MBA, MHS, CCP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 ALISHA LN
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-5730
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-982-7226
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-10
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT83.000085242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist