Provider Demographics
NPI:1548336258
Name:RODERICK, CAROLYN ANN (PHYSICIANS ASSISTANT)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:RODERICK
Suffix:
Gender:F
Credentials:PHYSICIANS ASSISTANT
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:ANN
Other - Last Name:HEWKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:170 GRANDVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2525
Mailing Address - Country:US
Mailing Address - Phone:203-759-3666
Mailing Address - Fax:203-759-3671
Practice Address - Street 1:170 GRANDVIEW AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2525
Practice Address - Country:US
Practice Address - Phone:203-759-3666
Practice Address - Fax:203-759-3671
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT290001360CT05OtherBLUE CROSS & BLUE SHIELD
CT004224490Medicaid
CT2V6845OtherHEALTHNET
CT004224490Medicaid
CT2V6845OtherHEALTHNET