Provider Demographics
NPI:1710061858
Name:PAWLAK, DOROTA
Entity Type:Individual
Prefix:MRS
First Name:DOROTA
Middle Name:
Last Name:PAWLAK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:DOROTA
Other - Middle Name:
Other - Last Name:BUBAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-2212
Practice Address - Country:US
Practice Address - Phone:860-679-8758
Practice Address - Fax:860-679-1824
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002949363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002949Other2
CT1710061858Medicaid
CTQ01243Medicare UPIN
CT500002243Medicare PIN