Healthcare Provider Details

I. General information

NPI: 1891255824
Provider Name (Legal Business Name): MAYA PETASHNICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK STREET TOMPKINS 226
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

20 YORK STREET TOMPKINS 226
NEW HAVEN CT
06510-3220
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-9503
  • Fax:
Mailing address:
  • Phone: 203-688-9503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number84003
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: