Provider Demographics
NPI:1093189136
Name:SPONZO, PATRICK
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:SPONZO
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 1:7 SAGE PARK RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-3327
Mailing Address - Country:US
Mailing Address - Phone:860-707-4653
Mailing Address - Fax:
Practice Address - Street 1:7 SAGE PARK RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06095-3327
Practice Address - Country:US
Practice Address - Phone:860-707-4653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-29
Last Update Date:2015-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT158696026390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program