Healthcare Provider Details

I. General information

NPI: 1578024105
Provider Name (Legal Business Name): VANCE P BAUGHMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 LAFAYETTE ST UNIT 1003
BRIDGEPORT CT
06604-5472
US

IV. Provider business mailing address

325 LAFAYETTE ST UNIT 1003
BRIDGEPORT CT
06604-5472
US

V. Phone/Fax

Practice location:
  • Phone: 443-814-3731
  • Fax:
Mailing address:
  • Phone: 443-814-3731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0008707
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: