Provider Demographics
NPI:1417549379
Name:WESELYJ, MARIA L (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:L
Last Name:WESELYJ
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 1:85 SEYMOUR ST STE 1003
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5529
Mailing Address - Country:US
Mailing Address - Phone:860-972-2780
Mailing Address - Fax:
Practice Address - Street 1:85 SEYMOUR ST STE 1003
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5529
Practice Address - Country:US
Practice Address - Phone:860-972-2780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT390200000X
CT5440363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program