Healthcare Provider Details

I. General information

NPI: 1700859576
Provider Name (Legal Business Name): TERRY SAPHR O'DONNELL PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 NEW LONDON TPKE STE 101
GLASTONBURY CT
06033-2246
US

IV. Provider business mailing address

131 NEW LONDON TPKE STE 101
GLASTONBURY CT
06033-2246
US

V. Phone/Fax

Practice location:
  • Phone: 860-659-8904
  • Fax:
Mailing address:
  • Phone: 860-659-8904
  • Fax: 860-246-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000644
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: