Basic Information
| Provider Information | |||||||||
| NPI: | 1801105036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BHARARA | ||||||||
| FirstName: | RAVNEET | ||||||||
| MiddleName: | KAUR | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 SCOVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034565292 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 80 PHOENIX AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067021418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037568021 | ||||||||
| FaxNumber: | 2034655222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2010 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 004489 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | 004489 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 008026219 | 05 | CT | MEDICAID |