Healthcare Provider Details

I. General information

NPI: 1710093869
Provider Name (Legal Business Name): TARA BRESLIN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 BLUE HILLS AVENUE MT.SINAI REHABILITATION HOSPITAL/ PHYSICIAN SUITE
HARTFORD CT
06112-3088
US

IV. Provider business mailing address

490 BLUE HILLS AVE MT SINAI REHABILITATION HOSPITAL/PHYSICIANS SUITE
HARTFORD CT
06112-1513
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-2647
  • Fax: 860-714-8519
Mailing address:
  • Phone: 860-714-2647
  • Fax: 860-714-8519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000593
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: