Basic Information
| Provider Information | |||||||||
| NPI: | 1639156342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAINSCOAT | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 JORDAN LN | ||||||||
| Address2: | PRIME HEALTHCARE | ||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061091278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602630253 | ||||||||
| FaxNumber: | 8602630262 | ||||||||
| Practice Location | |||||||||
| Address1: | 27 SYCAMORE ST | ||||||||
| Address2: | STE 100, PRIME HEALTHCARE | ||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060332223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606590581 | ||||||||
| FaxNumber: | 8606523077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2005 | ||||||||
| LastUpdateDate: | 11/16/2009 | ||||||||
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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 | 207R00000X | 042898 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001428988 | 05 | CT | MEDICAID | BW9001051 | 01 | CT | DEA | OTHER | 040042898CT01 | 01 | CT | BCBS | OTHER | 042898 | 01 | CT | MEDICAL LICENSE | OTHER |