Provider Demographics
NPI:1073999629
Name:SHIELDS, NICOLE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:SHIELDS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:ADAMIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2689 SOLUTION CENTER
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-2464
Mailing Address - Country:US
Mailing Address - Phone:586-329-1880
Mailing Address - Fax:586-231-0055
Practice Address - Street 1:133 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2308
Practice Address - Country:US
Practice Address - Phone:586-468-1600
Practice Address - Fax:586-465-0329
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007332363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5315080570OtherCONTROLLED SUBSTANCE LICENSE
MI5601007332OtherPHYSICIAN ASSISTANT LICENSE
MIMA3671369OtherDEA