Provider Demographics
NPI:1447371596
Name:SHEA, MICHAEL D (APRN-BC)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:SHEA
Suffix:
Gender:M
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:339 WEST MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001
Mailing Address - Country:US
Mailing Address - Phone:860-696-2150
Mailing Address - Fax:860-696-2160
Practice Address - Street 1:339 WEST MAIN ST.
Practice Address - Street 2:HARTFORD HEALTHCARE MEDICAL MEDICAL GROUP
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001
Practice Address - Country:US
Practice Address - Phone:860-696-2150
Practice Address - Fax:860-696-2160
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002600363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500000967Medicare ID - Type Unspecified