Provider Demographics
NPI:1770868408
Name:HANJAN-FUSCO, KAWAL (PA)
Entity Type:Individual
Prefix:
First Name:KAWAL
Middle Name:
Last Name:HANJAN-FUSCO
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 1:110 DUNHAM PL
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-1201
Mailing Address - Country:US
Mailing Address - Phone:860-545-7602
Mailing Address - Fax:
Practice Address - Street 1:110 DUNHAM PL
Practice Address - Street 2:HARTFORD HOSPITAL EMERGENCY ROOM
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-1201
Practice Address - Country:US
Practice Address - Phone:860-670-3546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002663363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003026630Medicaid
CTD400058250 - C00814Medicare PIN
CTD400058251 - C00023Medicare PIN