Provider Demographics
NPI:1487821401
Name:TEDESCO, JANINE A (PA-C)
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:A
Last Name:TEDESCO
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 OLD KINGS HWY N
Mailing Address - Street 2:
Mailing Address - City:DARIEN
Mailing Address - State:CT
Mailing Address - Zip Code:06820-4732
Mailing Address - Country:US
Mailing Address - Phone:203-425-2790
Mailing Address - Fax:203-425-2794
Practice Address - Street 1:85 OLD KINGS HWY N
Practice Address - Street 2:
Practice Address - City:DARIEN
Practice Address - State:CT
Practice Address - Zip Code:06820-4732
Practice Address - Country:US
Practice Address - Phone:203-425-2790
Practice Address - Fax:203-425-2794
Is Sole Proprietor?:No
Enumeration Date:2008-05-08
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011301363A00000X
CT2234363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400003157Medicare PIN