=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992472450
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SARAH DALLAIRE RONCAIOLI PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2021
-----------------------------------------------------
Last Update Date | 06/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 GRAND ST
-----------------------------------------------------
City | HARTFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06106-1541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-550-7500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1036R SUFFIELD ST
-----------------------------------------------------
City | AGAWAM
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01001-2931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-324-3867
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5339
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 23.005339
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------