Provider Demographics
NPI:1174195572
Name:DELUCA, HANNAH (PAC)
Entity Type:Individual
Prefix:
First Name:HANNAH
Middle Name:
Last Name:DELUCA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:HANNAH
Other - Middle Name:
Other - Last Name:GOULIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:252 TRYON ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4536
Mailing Address - Country:US
Mailing Address - Phone:860-301-2002
Mailing Address - Fax:
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty