Provider Demographics
NPI:1225206543
Name:REILLY, MARIANNE IRENE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:IRENE
Last Name:REILLY
Suffix:
Gender:F
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 1:30 SHELBURNE RD/W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06904
Mailing Address - Country:US
Mailing Address - Phone:203-276-1000
Mailing Address - Fax:
Practice Address - Street 1:30 SHELBURNE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3628
Practice Address - Country:US
Practice Address - Phone:203-276-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000339363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT000339OtherCT STATE LICENSE