Provider Demographics
NPI:1447287826
Name:BRADY, THOMAS G (PA-C)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:G
Last Name:BRADY
Suffix:
Gender:M
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:P.O. BOX 208237
Mailing Address - Street 2:55 LOCK STREET
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06520-8237
Mailing Address - Country:US
Mailing Address - Phone:203-432-0076
Mailing Address - Fax:203-432-7289
Practice Address - Street 1:55 LOCK STREET
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06520-8237
Practice Address - Country:US
Practice Address - Phone:203-432-0076
Practice Address - Fax:203-432-7289
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT197363AS0400X
CT000197363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTQ01656Medicare UPIN