Provider Demographics
NPI:1831590454
Name:TANGUAY, MICHAEL (PA-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:TANGUAY
Suffix:
Gender:M
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 1:7 POTTER SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:WILLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06279-2412
Mailing Address - Country:US
Mailing Address - Phone:860-933-3806
Mailing Address - Fax:
Practice Address - Street 1:1625 STRAITS TPKE
Practice Address - Street 2:SUITE 200
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1836
Practice Address - Country:US
Practice Address - Phone:203-759-0666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3142363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant