Provider Demographics
NPI:1407171085
Name:ABRAHAM, CELIN (PA-C)
Entity Type:Individual
Prefix:
First Name:CELIN
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CELIN
Other - Middle Name:
Other - Last Name:CHACKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:56 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1253
Mailing Address - Country:US
Mailing Address - Phone:203-709-6000
Mailing Address - Fax:
Practice Address - Street 1:56 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1253
Practice Address - Country:US
Practice Address - Phone:203-709-6000
Practice Address - Fax:203-709-7753
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002285363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1407171085OtherANTHEM BCBS CT
CT008018870Medicaid
CT643896OtherWELLCARE
CT9579623OtherAETNA
CTD400023509Medicare PIN