Provider Demographics
NPI:1982287538
Name:PENNACCHIA, MATTHEW VANCE
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:VANCE
Last Name:PENNACCHIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 BROADBRIDGE AVE UNIT B27
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5493
Mailing Address - Country:US
Mailing Address - Phone:203-722-3028
Mailing Address - Fax:
Practice Address - Street 1:521 BOSTON POST RD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-3506
Practice Address - Country:US
Practice Address - Phone:203-529-3271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-02
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5310363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty