Provider Demographics
NPI:1376739623
Name:MARINGOLA, RYAN WILLIAM (PA)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:WILLIAM
Last Name:MARINGOLA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 FIELDSTONE CMNS
Mailing Address - Street 2:SUITE D
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-3419
Mailing Address - Country:US
Mailing Address - Phone:860-875-2099
Mailing Address - Fax:860-872-3021
Practice Address - Street 1:6 FIELDSTONE CMNS STE D
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-3419
Practice Address - Country:US
Practice Address - Phone:860-875-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1969363A00000X
CT001969363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1376739623Medicaid