Provider Demographics
NPI:1265510614
Name:SHEARD, SUSAN DIANE (PA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DIANE
Last Name:SHEARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 E MICHIGAN AVE
Mailing Address - Street 2:STE 201
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1847
Mailing Address - Country:US
Mailing Address - Phone:517-789-7122
Mailing Address - Fax:517-789-5229
Practice Address - Street 1:1100 E MICHIGAN AVE
Practice Address - Street 2:STE 201
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1847
Practice Address - Country:US
Practice Address - Phone:517-789-7122
Practice Address - Fax:517-789-5229
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004448363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP10730001Medicare ID - Type Unspecified