Provider Demographics
NPI:1407826522
Name:MICHAUD, DEANNA (PA)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:
Last Name:MICHAUD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 JEROME AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06013-2434
Mailing Address - Country:US
Mailing Address - Phone:860-490-5953
Mailing Address - Fax:
Practice Address - Street 1:70 HEMINWAY PARK RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:CT
Practice Address - Zip Code:06795-2612
Practice Address - Country:US
Practice Address - Phone:203-709-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001269363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010269OtherCONNECTICARE
CT7346891OtherAETNA
CTPENDINGOtherRR MEDICARE
CT004245272Medicaid
CT1192828OtherUSA
CT010269OtherCONNECTICARE
P80475Medicare UPIN
CT7346891OtherAETNA