Provider Demographics
NPI:1073579694
Name:MASTROIANNI, VIVIAN M (PA C)
Entity Type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:M
Last Name:MASTROIANNI
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:73 SAND PIT RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-4042
Mailing Address - Country:US
Mailing Address - Phone:203-792-4151
Mailing Address - Fax:203-792-4155
Practice Address - Street 1:73 SAND PIT RD
Practice Address - Street 2:SUITE 207
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4042
Practice Address - Country:US
Practice Address - Phone:203-792-4151
Practice Address - Fax:203-792-4155
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970002507Medicare PIN
S19054Medicare UPIN