Provider Demographics
NPI:1962022129
Name:ITO, BRANDON (PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:ITO
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 1:1290 SILAS DEANE HWY
Mailing Address - Street 2:HARTFORD HEALTHCARE-CVO
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:455 LEWIS AVE STE 221
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2121
Practice Address - Country:US
Practice Address - Phone:203-694-8550
Practice Address - Fax:203-694-7698
Is Sole Proprietor?:No
Enumeration Date:2020-04-17
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5422363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant