Provider Demographics
NPI:1972544864
Name:PAWLAK, MAUREEN (PA)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:PAWLAK
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 1:25 BRYAN RD
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-4503
Mailing Address - Country:US
Mailing Address - Phone:203-483-8620
Mailing Address - Fax:
Practice Address - Street 1:1450 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4405
Practice Address - Country:US
Practice Address - Phone:203-789-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000057363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970000476Medicare ID - Type Unspecified
CT573907Medicare UPIN