Provider Demographics
NPI:1710093869
Name:BRESLIN, TARA (PAC)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BRESLIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490 BLUE HILLS AVE
Mailing Address - Street 2:MT SINAI REHABILITATION HOSPITAL/PHYSICIANS SUITE
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1513
Mailing Address - Country:US
Mailing Address - Phone:860-714-2647
Mailing Address - Fax:860-714-8519
Practice Address - Street 1:490 BLUE HILLS AVENUE
Practice Address - Street 2:MT.SINAI REHABILITATION HOSPITAL/ PHYSICIAN SUITE
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-3088
Practice Address - Country:US
Practice Address - Phone:860-714-2647
Practice Address - Fax:860-714-8519
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CT000593363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0005930121OtherCONNECTICARE
CT290000593CT03OtherBLUE CROSS BLUE SHIELD
CT290000593CT03OtherBLUE CROSS BLUE SHIELD
CTR65365Medicare UPIN