Healthcare Provider Details

I. General information

NPI: 1528974060
Provider Name (Legal Business Name): ALYSSA KIARA ROACH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 GRAND ST
HARTFORD CT
06106-1541
US

IV. Provider business mailing address

30 CARLETON RD
WEST HARTFORD CT
06107-3711
US

V. Phone/Fax

Practice location:
  • Phone: 860-550-7500
  • Fax:
Mailing address:
  • Phone: 860-422-5659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number7902
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: