Basic Information
| Provider Information | |||||||||
| NPI: | 1578704615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALTMAN | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415933 | ||||||||
| Address2: | HARTFORD HOSPITAL PROFESSIONAL SERVICES | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605457602 | ||||||||
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| Practice Location | |||||||||
| Address1: | 80 SEYMOUR STREET | ||||||||
| Address2: | HARTFORD HOSPITAL SURGERY DEPT | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061025037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609724670 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2009 | ||||||||
| LastUpdateDate: | 01/13/2014 | ||||||||
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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 | 363A00000X | 002350 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 002350 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 002350 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 003023504 | 05 | CT | MEDICAID |