Provider Demographics
NPI:1316204472
Name:IRANI, ROXANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:IRANI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ROXANNE
Other - Middle Name:ADIL
Other - Last Name:GANDHY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 415933
Mailing Address - Street 2:HARTFORD HOSPITAL PROFESSIONAL SERVICES
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-5933
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:80 SEYMOUR STREET
Practice Address - Street 2:HARTFORD HOSPITAL MEDICINE ICU
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06102-5307
Practice Address - Country:US
Practice Address - Phone:860-545-2085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002739363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003027307Medicaid