Healthcare Provider Details

I. General information

NPI: 1851373591
Provider Name (Legal Business Name): DANIEL DE JESUS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 04/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEYMOUR ST SUITE 200
HARTFORD CT
06106-5501
US

IV. Provider business mailing address

134 GRANDVIEW AVE SUITE 101
WATERBURY CT
06708-2507
US

V. Phone/Fax

Practice location:
  • Phone: 860-289-3375
  • Fax: 860-783-5733
Mailing address:
  • Phone: 203-756-8911
  • Fax: 203-574-0548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000848
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: