Provider Demographics
NPI:1326715202
Name:BROXUP, SHANA GOETTING (PA)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:GOETTING
Last Name:BROXUP
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:8550 MOUNTAIN PINE LN
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-4992
Mailing Address - Country:US
Mailing Address - Phone:517-896-9426
Mailing Address - Fax:
Practice Address - Street 1:3230 EAGLE PARK DR NE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7047
Practice Address - Country:US
Practice Address - Phone:616-988-2229
Practice Address - Fax:616-988-2010
Is Sole Proprietor?:No
Enumeration Date:2021-08-27
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601010535TMP21363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant