Provider Demographics
NPI:1467499624
Name:O'KEEFE, SHANNON KATHLEEN (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KATHLEEN
Last Name:O'KEEFE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KATHLEEN
Other - Last Name:REED
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE
Mailing Address - Street 2:MC845
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 S GREENVILLE WEST DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-3514
Practice Address - Country:US
Practice Address - Phone:616-754-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004494363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q67364Medicare UPIN
MI0N38550040Medicare ID - Type Unspecified