Healthcare Provider Details

I. General information

NPI: 1326676156
Provider Name (Legal Business Name): SHANE DUELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2020
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 MAPLE ST
NORWALK CT
06850-3815
US

IV. Provider business mailing address

833 ROLINS RUN
WEBSTER NY
14580-8400
US

V. Phone/Fax

Practice location:
  • Phone: 203-852-2188
  • Fax:
Mailing address:
  • Phone: 585-281-4109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4993
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4993
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: