Provider Demographics
NPI:1790858058
Name:ANASTASIADIS, IOANNA (PA)
Entity Type:Individual
Prefix:
First Name:IOANNA
Middle Name:
Last Name:ANASTASIADIS
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 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:147 WESTBROOK RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:CT
Practice Address - Zip Code:06426-1512
Practice Address - Country:US
Practice Address - Phone:860-767-8265
Practice Address - Fax:860-358-8653
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000621363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS59464Medicare UPIN
CT970000233Medicare PIN