Provider Demographics
NPI:1437778677
Name:RYDZEWSKA, STACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:RYDZEWSKA
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 1:263 FARMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-8063
Mailing Address - Country:US
Mailing Address - Phone:860-679-2626
Mailing Address - Fax:860-679-1223
Practice Address - Street 1:263 FARMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-8063
Practice Address - Country:US
Practice Address - Phone:860-679-2626
Practice Address - Fax:860-679-1223
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
CT4901363A00000X, 207RR0500X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology