Basic Information
| Provider Information | |||||||||
| NPI: | 1780604017 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | PELLETIER | ||||||||
| FirstName: | BARBARA | ||||||||
| MiddleName: | KURAITIS | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | DEPT. 200 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061462699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8668987138 | ||||||||
| FaxNumber: | 6169759824 | ||||||||
| Practice Location | |||||||||
| Address1: | 56 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037096004 | ||||||||
| FaxNumber: | 2037093700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 04/30/2013 | ||||||||
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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 | 000465 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | D400009238 | 01 | CT | MEDICARE PTAN FOR JOHN DEMPSEY HOSPITAL | OTHER |