Provider Demographics
NPI:1629253976
Name:KOLESNIK, SUANNE (PA)
Entity Type:Individual
Prefix:MRS
First Name:SUANNE
Middle Name:
Last Name:KOLESNIK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 POMEROY AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-7101
Mailing Address - Country:US
Mailing Address - Phone:203-694-5350
Mailing Address - Fax:203-694-7650
Practice Address - Street 1:61 POMEROY AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06450-7101
Practice Address - Country:US
Practice Address - Phone:203-694-5350
Practice Address - Fax:203-694-7650
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001945363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant