Provider Demographics
NPI:1306190368
Name:STOCKWELL, SHANNON R (PA-C)
Entity Type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:R
Last Name:STOCKWELL
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:2655 E OAKLEY PARK RD STE 202
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-1684
Mailing Address - Country:US
Mailing Address - Phone:248-487-8222
Mailing Address - Fax:832-324-6942
Practice Address - Street 1:2655 E OAKLEY PARK RD STE 202
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48390-1684
Practice Address - Country:US
Practice Address - Phone:248-487-8222
Practice Address - Fax:832-324-6942
Is Sole Proprietor?:No
Enumeration Date:2012-10-30
Last Update Date:2022-02-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006541363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant