Healthcare Provider Details

I. General information

NPI: 1194842336
Provider Name (Legal Business Name): JACQUELINE SANZ P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2007
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BREWSTER ROAD
BRISTOL CT
06010-5142
US

IV. Provider business mailing address

PO BOX 2828
BRISTOL CT
06011-2828
US

V. Phone/Fax

Practice location:
  • Phone: 860-585-3000
  • Fax: 860-585-3907
Mailing address:
  • Phone: 860-585-3906
  • Fax: 860-585-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001836
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: