Healthcare Provider Details

I. General information

NPI: 1215778410
Provider Name (Legal Business Name): SANDRA PINEDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2024
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 MAIN ST
BRIDGEPORT CT
06606-4201
US

IV. Provider business mailing address

1290 SILAS DEANE HWY
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 203-576-6141
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number7751
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: