Provider Demographics
NPI:1487836961
Name:CALLAHAN, GWEN S (PA C)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:S
Last Name:CALLAHAN
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 1:50505 SCHOENHERR RD
Mailing Address - Street 2:SUITE 290
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-3140
Mailing Address - Country:US
Mailing Address - Phone:586-314-0054
Mailing Address - Fax:586-731-6275
Practice Address - Street 1:500 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186-3027
Practice Address - Country:US
Practice Address - Phone:540-316-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006327363A00000X
MDC07550363A00000X
MI5601005001363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F34972Medicare PIN