Healthcare Provider Details

I. General information

NPI: 1174195572
Provider Name (Legal Business Name): HANNAH DELUCA PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: HANNAH GOULIS PAC

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 WOODLAND ST
HARTFORD CT
06105-1208
US

IV. Provider business mailing address

252 TRYON ST
MIDDLETOWN CT
06457-4536
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4000
  • Fax:
Mailing address:
  • Phone: 860-301-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: