Provider Demographics
NPI:1437771698
Name:PADUCH, MICHAELA ANNE
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:ANNE
Last Name:PADUCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 INJUN HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:EAST HAMPTON
Mailing Address - State:CT
Mailing Address - Zip Code:06424-3022
Mailing Address - Country:US
Mailing Address - Phone:860-581-0308
Mailing Address - Fax:
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4292
Practice Address - Country:US
Practice Address - Phone:203-576-6120
Practice Address - Fax:203-576-6020
Is Sole Proprietor?:No
Enumeration Date:2020-05-11
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4915363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant