Healthcare Provider Details

I. General information

NPI: 1962551804
Provider Name (Legal Business Name): PATRICIA L SEBASTIAN MD.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 11/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 RT 2 MANSHANTUCKET PEQUOT TRIBAL HEALT SERVICES
LEDYARD CT
06338-3260
US

IV. Provider business mailing address

PO BOX 3260 75 RT 2 MANSHANTUCKET PEQUOT TRIBAL HEALTH DEPT.
LEDYARD CT
06338-3260
US

V. Phone/Fax

Practice location:
  • Phone: 860-312-8000
  • Fax: 860-312-8001
Mailing address:
  • Phone: 860-312-8000
  • Fax: 860-312-8001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD42618
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD42618
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD42618
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD42618
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: