Healthcare Provider Details

I. General information

NPI: 1659307916
Provider Name (Legal Business Name): LISA MARIE TANGUAY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE WARYCH PA

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 FRANKLIN ST
WATERBURY CT
06706-1221
US

IV. Provider business mailing address

56 FRANKLIN ST 3RD FLOOR
WATERBURY CT
06706-1221
US

V. Phone/Fax

Practice location:
  • Phone: 203-709-6314
  • Fax: 203-709-6089
Mailing address:
  • Phone: 203-709-8873
  • Fax: 203-709-8689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000863
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number000863
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: