Provider Demographics
NPI:1366596553
Name:DAWSON, MICHAEL J (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:DAWSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MERIDEN AVE STE 3G
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3235
Mailing Address - Country:US
Mailing Address - Phone:860-827-7690
Mailing Address - Fax:860-827-7696
Practice Address - Street 1:55 MERIDEN AVE STE 3G
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3235
Practice Address - Country:US
Practice Address - Phone:860-827-7690
Practice Address - Fax:860-827-7696
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004101363AS0400X
NY008002363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q57391Medicare UPIN
6035L1Medicare ID - Type Unspecified