Basic Information
Provider Information | |||||||||
NPI: | 1457684862 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KIREYCZYK | ||||||||
FirstName: | KARA | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CALLAHAN | ||||||||
OtherFirstName: | KARA | ||||||||
OtherMiddleName: | ANN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2139 SILAS DEANE HWY | ||||||||
Address2: |   | ||||||||
City: | ROCKY HILL | ||||||||
State: | CT | ||||||||
PostalCode: | 060672336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8602574131 | ||||||||
FaxNumber: | 8622574519 | ||||||||
Practice Location | |||||||||
Address1: | 85 SEYMOUR ST | ||||||||
Address2: | SUITE 1000 | ||||||||
City: | HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061065501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8602462571 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/16/2009 | ||||||||
LastUpdateDate: | 11/05/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 002342 | CT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 002342 | CT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.