Provider Demographics
NPI:1396864559
Name:SHULL, DONNA M (PA-C)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:SHULL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4206 WABANINGO RD
Mailing Address - Street 2:
Mailing Address - City:OKEMOS
Mailing Address - State:MI
Mailing Address - Zip Code:48864-4405
Mailing Address - Country:US
Mailing Address - Phone:517-349-3114
Mailing Address - Fax:
Practice Address - Street 1:804 SERVICE ROAD
Practice Address - Street 2:ROOM A142
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-7039
Practice Address - Country:US
Practice Address - Phone:517-353-3050
Practice Address - Fax:517-432-3742
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant