Provider Demographics
NPI:1902888936
Name:DOBACK, JOAN M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:M
Last Name:DOBACK
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 1:57 MARBERN LN
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-1613
Mailing Address - Country:US
Mailing Address - Phone:203-729-9799
Mailing Address - Fax:
Practice Address - Street 1:64 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2613
Practice Address - Country:US
Practice Address - Phone:203-573-7233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000167363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTS47929Medicare UPIN