Provider Demographics
NPI:1659307916
Name:TANGUAY, LISA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:TANGUAY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:WARYCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:56 FRANKLIN ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06706-1221
Mailing Address - Country:US
Mailing Address - Phone:203-709-8873
Mailing Address - Fax:203-709-8689
Practice Address - Street 1:56 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1221
Practice Address - Country:US
Practice Address - Phone:203-709-6314
Practice Address - Fax:203-709-6089
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000863363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT061470493OtherCOVENTRY/FIRST HEALTH
CT080863OtherCONNECTICARE
CT290000863CT11OtherANTHEM BCBS CT
CT2V1632OtherHEALTHNET/COMMERCIAL
CT008010398Medicaid
CT208796OtherWELLCARE
CT22-59899OtherAMERICHOICE
CT877800OtherUSA
CT9886225OtherAETNA
CTP3134207OtherOXFORD
CT208796OtherWELLCARE
CT22-59899OtherAMERICHOICE