Healthcare Provider Details

I. General information

NPI: 1154728400
Provider Name (Legal Business Name): MARY RYAN CALNEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2014
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 MEMORIAL RD STE 508
WEST HARTFORD CT
06107-4233
US

IV. Provider business mailing address

80 SEYMOUR STREET HARTFORD HOSPITAL SURGERY DEPT
HARTFORD CT
06102-5037
US

V. Phone/Fax

Practice location:
  • Phone: 860-696-2925
  • Fax:
Mailing address:
  • Phone: 860-972-4670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003233
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number003233
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003233
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: