Provider Demographics
NPI:1528665197
Name:COADY, MIKAELA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:ROSE
Last Name:COADY
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 1:464 CONGRESS AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1362
Mailing Address - Country:US
Mailing Address - Phone:203-785-4404
Mailing Address - Fax:203-785-4580
Practice Address - Street 1:464 CONGRESS AVE STE 260
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1362
Practice Address - Country:US
Practice Address - Phone:203-785-4404
Practice Address - Fax:203-785-4580
Is Sole Proprietor?:No
Enumeration Date:2020-10-06
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4946363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1169367OtherNCCPA NATIONAL CERTIFICATION
CT4946OtherSTATE LICENSE