Provider Demographics
NPI:1174510424
Name:CONWAY, JUDITH (APRN)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:CONWAY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 KANE ST
Mailing Address - Street 2:PROVIDER ENROLLMENT, 2ND FLOOR
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119-2110
Mailing Address - Country:US
Mailing Address - Phone:860-523-6421
Mailing Address - Fax:860-523-3701
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:GASTROENTEROLOGY ASSOCIATES
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-3238
Practice Address - Fax:860-679-1217
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000552364SM0705X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4223442Medicaid
CT4223442Medicaid
CTP60319Medicare UPIN