=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902888936
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOAN M DOBACK PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2005
-----------------------------------------------------
Last Update Date | 09/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 64 ROBBINS ST
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06708-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-573-7233
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57 MARBERN LN
-----------------------------------------------------
City | NAUGATUCK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06770-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-729-9799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | 000167
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------