Provider Demographics
NPI:1568460566
Name:STANNARD, JUDITH M (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:STANNARD
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
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
Mailing Address - Street 2:SUITE 607
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-549-3210
Mailing Address - Fax:860-247-3803
Practice Address - Street 1:6320 N LA CHOLLA BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85741-3549
Practice Address - Country:US
Practice Address - Phone:520-382-8200
Practice Address - Fax:520-297-3505
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001249363A00000X, 363AM0700X
AZ6935363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP72675Medicare UPIN
CT970001169Medicare ID - Type UnspecifiedPROVIDER NUMBER