Basic Information
| Provider Information | |||||||||
| NPI: | 1245437037 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAGNUCCO | ||||||||
| FirstName: | JONICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | YERZAK | ||||||||
| OtherFirstName: | JONICA | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 455 LEWIS AVE | ||||||||
| Address2: | STE 221 | ||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064512121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035739512 | ||||||||
| FaxNumber: | 2035682904 | ||||||||
| Practice Location | |||||||||
| Address1: | 64 ROBBINS ST | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035736263 | ||||||||
| FaxNumber: | 2035736030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 05/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 001913 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.