Basic Information
| Provider Information | |||||||||
| NPI: | 1689985228 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SNIDER | ||||||||
| FirstName: | SHANNON | ||||||||
| MiddleName: | GABRIELLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUTY | ||||||||
| OtherFirstName: | SHANNON | ||||||||
| OtherMiddleName: | GABRIELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3434 M 119 STE C | ||||||||
| Address2: | |||||||||
| City: | HARBOR SPRINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497409373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313489900 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3434 M 119 STE C | ||||||||
| Address2: | |||||||||
| City: | HARBOR SPRINGS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497409373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313489900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2010 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 5601005686 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 5601005686 | 01 | MI | LICENSE # | OTHER |