Basic Information
| Provider Information | |||||||||
| NPI: | 1932671575 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAWIAH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LONG WHARF DR STE 321 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 LONG WHARF DR STE 321 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065115946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037814600 | ||||||||
| FaxNumber: | 2037814624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2018 | ||||||||
| LastUpdateDate: | 01/15/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 7930 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 004217099 | 05 | CT | MEDICAID | 008084657 | 05 | CT | MEDICAID |