Basic Information
Provider Information | |||||||||
NPI: | 1821038217 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GABEL DORR | ||||||||
FirstName: | SHANNON | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 829 N CENTER AVE | ||||||||
Address2: | SUITE 298 | ||||||||
City: | GAYLORD | ||||||||
State: | MI | ||||||||
PostalCode: | 497351595 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897317708 | ||||||||
FaxNumber: | 9897317929 | ||||||||
Practice Location | |||||||||
Address1: | 2147 PROFESSIONAL DR | ||||||||
Address2: |   | ||||||||
City: | GAYLORD | ||||||||
State: | MI | ||||||||
PostalCode: | 497350003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9897321753 | ||||||||
FaxNumber: | 9897311425 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2006 | ||||||||
LastUpdateDate: | 11/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 249 | WY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 314309 | 01 | WY | BLUE CROSS BLUE SHIELD WY | OTHER | 4310527 | 05 | MT |   | MEDICAID | 117064300 | 05 | WY |   | MEDICAID | 5601005656 | 01 | MI | MI LICENSE | OTHER | 314247 | 01 | WY | BLUE CROSS BLUE SHIELD WY | OTHER | 900213 | 01 | MT | BLUE CROSS BLUE SHIELD MT | OTHER |