Provider Demographics
NPI:1114598638
Name:DUFEK, SHANNON RAE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:RAE
Last Name:DUFEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SHANNON
Other - Middle Name:RAE
Other - Last Name:FISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:119 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:BARAGA
Mailing Address - State:MI
Mailing Address - Zip Code:49908-9676
Mailing Address - Country:US
Mailing Address - Phone:906-201-2499
Mailing Address - Fax:
Practice Address - Street 1:18341 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:LANSE
Practice Address - State:MI
Practice Address - Zip Code:49946-8024
Practice Address - Country:US
Practice Address - Phone:906-525-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010681363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty