Provider Demographics
NPI:1932125036
Name:CERVONKA, DANIEL (PA-C, MPAS, CAS)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:CERVONKA
Suffix:
Gender:M
Credentials:PA-C, MPAS, CAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 A P GATES RD
Mailing Address - Street 2:
Mailing Address - City:EAST HADDAM
Mailing Address - State:CT
Mailing Address - Zip Code:06423-1523
Mailing Address - Country:US
Mailing Address - Phone:860-873-3512
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-9703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000159363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS11765Medicare UPIN