Provider Demographics
NPI:1346401601
Name:KUSIAK, SHANNON KAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:KAY
Last Name:KUSIAK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:24 FRANK LLOYD WRIGHT DR LBBY J2000
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9484
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4940 W CLARK RD
Practice Address - Street 2:STE 100
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-0860
Practice Address - Country:US
Practice Address - Phone:734-971-1188
Practice Address - Fax:734-971-3658
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2018-01-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301092619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine