Provider Demographics
NPI:1982672564
Name:MAURER, BRIAN THOMAS (PA)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:THOMAS
Last Name:MAURER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:TARIFFVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06081-9636
Mailing Address - Country:US
Mailing Address - Phone:860-651-9940
Mailing Address - Fax:
Practice Address - Street 1:155 HAZARD AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4580
Practice Address - Country:US
Practice Address - Phone:860-749-3169
Practice Address - Fax:860-749-2670
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2013-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000073363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008036364Medicaid