Healthcare Provider Details

I. General information

NPI: 1346768066
Provider Name (Legal Business Name): ROBERT PAUL BLAISDELL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MAPLE ST
NORWALK CT
06850-3815
US

IV. Provider business mailing address

28 JOSEPH LN
COLCHESTER CT
06415-2039
US

V. Phone/Fax

Practice location:
  • Phone: 203-852-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: