Basic Information
| Provider Information | |||||||||
| NPI: | 1871085381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAYSON | ||||||||
| FirstName: | SHANNON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 E MEDICAL CENTER DRIVE | ||||||||
| Address2: | TAUBMAN CENTER, 1ST FLOOR, ROOM 1903 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095312 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1500 E MEDICAL CENTER DRIVE | ||||||||
| Address2: | TAUBMAN CENTER, 1ST FLOOR, ROOM 1903 | ||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481095312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347369178 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2018 | ||||||||
| LastUpdateDate: | 05/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 4301115213 | MI | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.