Provider Demographics
NPI:1053689489
Name:BRONSTEIN, WANDA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:WANDA
Middle Name:
Last Name:BRONSTEIN
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 1:1000 ASYLUM AVE STE 3212
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1702
Mailing Address - Country:US
Mailing Address - Phone:860-522-1711
Mailing Address - Fax:860-493-6524
Practice Address - Street 1:1000 ASYLUM AVE STE 3212
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1702
Practice Address - Country:US
Practice Address - Phone:860-522-1171
Practice Address - Fax:860-493-6524
Is Sole Proprietor?:No
Enumeration Date:2011-12-13
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2693363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5258AMedicare UPIN