Provider Demographics
NPI:1548280175
Name:ROLDAN, LYDIA R (NP)
Entity type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:R
Last Name:ROLDAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30 LOEFFLER RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2256
Mailing Address - Country:US
Mailing Address - Phone:860-513-5420
Mailing Address - Fax:860-263-0262
Practice Address - Street 1:500 ALBANY AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06120-2508
Practice Address - Country:US
Practice Address - Phone:860-808-8748
Practice Address - Fax:860-808-1580
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001256363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004176493Medicaid