Provider Demographics
NPI:1285190462
Name:JOHN, KEREN MARIAM (PA- CERTIFIED)
Entity type:Individual
Prefix:
First Name:KEREN
Middle Name:MARIAM
Last Name:JOHN
Suffix:
Gender:F
Credentials:PA- CERTIFIED
Other - Prefix:
Other - First Name:KEREN
Other - Middle Name:MARIAM
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:COMMUNITY HEALTH CENTER
Mailing Address - Street 2:675 MAIN STREET
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:516-510-4160
Mailing Address - Fax:
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-13
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4523363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant