Provider Demographics
NPI:1689368466
Name:GRAGNOLATI, IAN (PA-C)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:GRAGNOLATI
Suffix:
Gender:M
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 1:25 ROBERTS ST
Mailing Address - Street 2:
Mailing Address - City:WINDSOR LOCKS
Mailing Address - State:CT
Mailing Address - Zip Code:06096-2113
Mailing Address - Country:US
Mailing Address - Phone:860-970-4913
Mailing Address - Fax:
Practice Address - Street 1:836 FARMINGTON AVE STE 207
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119-1551
Practice Address - Country:US
Practice Address - Phone:860-232-9911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6212363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant