Provider Demographics
NPI:1063242303
Name:WRIGHT, MICAH DAVID (CT)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:DAVID
Last Name:WRIGHT
Suffix:
Gender:M
Credentials:CT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 W RALEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44907-1334
Mailing Address - Country:US
Mailing Address - Phone:330-414-4576
Mailing Address - Fax:
Practice Address - Street 1:169 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1832
Practice Address - Country:US
Practice Address - Phone:567-292-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC.2405993-TRNE390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program