Healthcare Provider Details

I. General information

NPI: 1831798362
Provider Name (Legal Business Name): BRANDON H KUSAKO PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2020
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GRAND ST
NEW BRITAIN CT
06052-2016
US

IV. Provider business mailing address

1290 SILAS DEANE HWY HHC CVO
WETHERSFIELD CT
06109-4337
US

V. Phone/Fax

Practice location:
  • Phone: 860-223-0800
  • Fax: 860-223-0444
Mailing address:
  • Phone: 860-972-5507
  • Fax: 860-972-7040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5069
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: