Provider Demographics
NPI:1508834920
Name:SHIPLEY, PETER (CRNA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:SHIPLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 W. 13 MILE RD
Mailing Address - Street 2:400 FSC-PCS
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6769
Mailing Address - Country:US
Mailing Address - Phone:248-423-2481
Mailing Address - Fax:
Practice Address - Street 1:3601 W. 13 MILE RD
Practice Address - Street 2:400 FSC-PCS
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6769
Practice Address - Country:US
Practice Address - Phone:248-423-2481
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704130451367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1745328Medicaid
MI1745328Medicaid