Healthcare Provider Details

I. General information

NPI: 1053628784
Provider Name (Legal Business Name): JESSICA VAZ MARTINS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2010
Last Update Date: 06/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 HAWLEY LN STE 2
TRUMBULL CT
06611-5387
US

IV. Provider business mailing address

160 HAWLEY LANE STE 002
TRUMBULL CT
06611
US

V. Phone/Fax

Practice location:
  • Phone: 203-375-3456
  • Fax: 203-380-3803
Mailing address:
  • Phone: 203-375-3456
  • Fax: 203-380-3803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number002445
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: