Healthcare Provider Details

I. General information

NPI: 1689654394
Provider Name (Legal Business Name): TED UBINA PAGULAYAN FNP-BC, APHN-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WAHOO AVE
GROTON CT
06340-2324
US

IV. Provider business mailing address

330 CRYSTAL AVE UNIT # 5
NEW LONDON CT
06320-6500
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-7512
  • Fax:
Mailing address:
  • Phone: 703-618-0689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number0001169726
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number30297876
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: