Provider Demographics
NPI:1023010634
Name:BAKANAUSKAS, AUDREY (APRN)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BAKANAUSKAS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ASYLUM AVE
Mailing Address - Street 2:SUITE 2109A
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-1770
Mailing Address - Country:US
Mailing Address - Phone:860-714-6581
Mailing Address - Fax:860-714-8311
Practice Address - Street 1:114 WOODLAND ST
Practice Address - Street 2:CARDIOLOGY
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-1208
Practice Address - Country:US
Practice Address - Phone:860-714-4161
Practice Address - Fax:860-714-8001
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001638363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004197639Medicaid
CT004197639Medicaid
CT890000234Medicare ID - Type Unspecified