Healthcare Provider Details

I. General information

NPI: 1932408002
Provider Name (Legal Business Name): KEVIN ANDREW BELANGER PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2011
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 MIDDLE TPKE W
MANCHESTER CT
06040-3834
US

IV. Provider business mailing address

1000 ASYLUM AVE STE 2108
HARTFORD CT
06105-1715
US

V. Phone/Fax

Practice location:
  • Phone: 860-432-4640
  • Fax:
Mailing address:
  • Phone: 860-525-4469
  • Fax: 860-278-2032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003073
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: