Basic Information
| Provider Information | |||||||||
| NPI: | 1427230804 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASTERSON | ||||||||
| FirstName: | DEANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 HAYNES ST | ||||||||
| Address2: | SUITE 1221 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605336595 | ||||||||
| FaxNumber: | 9605336594 | ||||||||
| Practice Location | |||||||||
| Address1: | 171 GRANDVIEW AVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067082517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035784630 | ||||||||
| FaxNumber: | 2035784629 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2007 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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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 | 363AS0400X | 002035 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | 2035 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1062414 | 01 | CT | NCCPA | OTHER |