Provider Demographics
NPI:1164756383
Name:DEVANNEY, MICHAEL D (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:DEVANNEY
Suffix:
Gender:M
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 1:270 FARMINGTON AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1909
Mailing Address - Country:US
Mailing Address - Phone:860-549-8276
Mailing Address - Fax:860-674-8084
Practice Address - Street 1:40 HART ST
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06052-1743
Practice Address - Country:US
Practice Address - Phone:860-549-3210
Practice Address - Fax:860-247-3803
Is Sole Proprietor?:No
Enumeration Date:2009-09-21
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2308363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1164756383OtherNPI