Provider Demographics
NPI:1356713978
Name:REARDON, JILLIAN STRASSNER (PA-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:STRASSNER
Last Name:REARDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:399 FARMINGTON AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1944
Mailing Address - Country:US
Mailing Address - Phone:860-548-7338
Mailing Address - Fax:
Practice Address - Street 1:399 FARMINGTON AVE STE 210
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1944
Practice Address - Country:US
Practice Address - Phone:860-548-7338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5533363A00000X
CT003434363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110113546AMedicaid