Basic Information
Provider Information | |||||||||
NPI: | 1629097175 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHINAULT | ||||||||
FirstName: | RHONDA | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A.-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PAUPARD | ||||||||
OtherFirstName: | RHONDA | ||||||||
OtherMiddleName: | L. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 815 ST JOSEPH DRIVE | ||||||||
Address2: |   | ||||||||
City: | ST JOSEPH | ||||||||
State: | MI | ||||||||
PostalCode: | 49085 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2699833455 | ||||||||
FaxNumber: | 2699835920 | ||||||||
Practice Location | |||||||||
Address1: | 520 RAILROAD ST | ||||||||
Address2: |   | ||||||||
City: | BANGOR | ||||||||
State: | MI | ||||||||
PostalCode: | 490131490 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2694275811 | ||||||||
FaxNumber: | 2694276107 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/18/2006 | ||||||||
LastUpdateDate: | 10/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601004817 | MI | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 1629097175 | 05 | MI |   | MEDICAID | 5601004817 | 01 | MI | PHYS. ASST. LICENSE NUMB | OTHER | P00888250 | 01 | MI | RR | OTHER |