Healthcare Provider Details

I. General information

NPI: 1992472450
Provider Name (Legal Business Name): SARAH DALLAIRE RONCAIOLI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2021
Last Update Date: 06/22/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GRAND ST
HARTFORD CT
06106-1541
US

IV. Provider business mailing address

1036R SUFFIELD ST
AGAWAM MA
01001-2931
US

V. Phone/Fax

Practice location:
  • Phone: 860-550-7500
  • Fax:
Mailing address:
  • Phone: 860-324-3867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number23.005339
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5339
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: