Provider Demographics
NPI:1083151898
Name:CLANCY, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CLANCY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BUNTING RD
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:CT
Mailing Address - Zip Code:06483-3829
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:425 POST RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6232
Practice Address - Country:US
Practice Address - Phone:203-292-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-31
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3766363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400369094Medicare PIN