Provider Demographics
NPI:1316987621
Name:KALISZEWSKI, TAMARA (PA)
Entity type:Individual
Prefix:MRS
First Name:TAMARA
Middle Name:
Last Name:KALISZEWSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1326
Mailing Address - Country:US
Mailing Address - Phone:203-732-1580
Mailing Address - Fax:203-732-1576
Practice Address - Street 1:130 DIVISION ST
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1326
Practice Address - Country:US
Practice Address - Phone:203-732-1580
Practice Address - Fax:203-732-1576
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPA000625363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTA752119OtherOXFORD
CT062500OtherCONNECTICARE
CT2V1674OtherHEALTHNET
CT290000625CT01OtherBLUE CROSS BLUE SHIELD
CTA752119OtherOXFORD