Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 69436 | CT |
N | 207Q00000X | Family Doctor | LP04070 | RI |
Y | 207QS0010X | Family Doctor - Sports Medicine | 69436 | CT |
NPI | 1306378104 |
---|---|
Provider Name | Kristofer Nathaniel Tupper |
First Address | Fairfield, CT 06825-5508 |
Second Address | Fairfield, CT 06825-5508 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2017 |
Last Update Date | 21/01/2022 |