Provider Demographics
NPI:1528500030
Name:SHABAZIAN, ANNMARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ANNMARIE
Middle Name:
Last Name:SHABAZIAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 TRUMBULL LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-2369
Mailing Address - Country:US
Mailing Address - Phone:860-299-5024
Mailing Address - Fax:
Practice Address - Street 1:330 CEDAR ST
Practice Address - Street 2:BB205
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3218
Practice Address - Country:US
Practice Address - Phone:203-785-2127
Practice Address - Fax:203-737-2163
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003609363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical