Provider Demographics
NPI:1043564941
Name:SHAMOUN, ANITA MARY (PA-C)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:MARY
Last Name:SHAMOUN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39080 PLUMBROOK DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48331-2972
Mailing Address - Country:US
Mailing Address - Phone:248-379-4648
Mailing Address - Fax:
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:313-966-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006497363AM0700X
COPA.0007438363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant