Healthcare Provider Details

I. General information

NPI: 1487386686
Provider Name (Legal Business Name): STEFANIA WYSK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HEBRON AVE STE 101
GLASTONBURY CT
06033-2176
US

IV. Provider business mailing address

300 HEBRON AVE STE 101
GLASTONBURY CT
06033-2176
US

V. Phone/Fax

Practice location:
  • Phone: 860-659-9990
  • Fax:
Mailing address:
  • Phone: 860-659-9990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5734
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: