Provider Demographics
NPI:1639482573
Name:BRADY, SHAWN RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:RICHARD
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 1:72 KINGFISHER CIR
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-4307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-4005
Practice Address - Country:US
Practice Address - Phone:860-684-8126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2417363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical