MEDICARE: DANIELLE M. TABAKA P.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	001698	CT
2	363AM0700X	Medical Physician Assistant	001698	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1698	OTHER	CT	CT LICENSE

General Provider Information

NPI Number	:	1972596997
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIELLE M. TABAKA P.A.

Provider Business Mailing Address
First Line	:	11 ARKONA DR
Second Line	:
City	:	HIGGANUM
State	:	CT
Zip	:	06441-4479
Country	:	US
Telephone Number	:	860-554-5021
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 ARKONA DR
Second Line	:
City	:	HIGGANUM
State	:	CT
Zip	:	06441-4479
Country	:	US
Telephone Number	:	860-554-5021
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	07/07/2014

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