Provider Demographics
NPI:1235988916
Name:SWANSON, KRISTEN RENEE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RENEE
Last Name:SWANSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:RENEE
Other - Last Name:MACMILLAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:41 BRETTON RD APT 6
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4175
Mailing Address - Country:US
Mailing Address - Phone:203-376-4514
Mailing Address - Fax:
Practice Address - Street 1:85 SEYMOUR ST STE 923
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5529
Practice Address - Country:US
Practice Address - Phone:860-524-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-15
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6687363AM0700X
CT363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical