Provider Demographics
NPI:1437816006
Name:KORSON, SHANNON (NP)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:KORSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 S CENTER HWY
Mailing Address - Street 2:
Mailing Address - City:SUTTONS BAY
Mailing Address - State:MI
Mailing Address - Zip Code:49682-9503
Mailing Address - Country:US
Mailing Address - Phone:231-590-3437
Mailing Address - Fax:
Practice Address - Street 1:3200 S CENTER HWY
Practice Address - Street 2:
Practice Address - City:SUTTONS BAY
Practice Address - State:MI
Practice Address - Zip Code:49682-9503
Practice Address - Country:US
Practice Address - Phone:231-590-3437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704292194363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner