Provider Demographics
NPI:1558549683
Name:MARTYNIAKPA, SHELLY R (PA)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:R
Last Name:MARTYNIAKPA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 S LINDEN RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-5475
Mailing Address - Country:US
Mailing Address - Phone:810-733-0790
Mailing Address - Fax:810-733-1817
Practice Address - Street 1:2222 S LINDEN RD
Practice Address - Street 2:SUITE A
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-5475
Practice Address - Country:US
Practice Address - Phone:810-733-0790
Practice Address - Fax:810-733-1817
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002850363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISM002850OtherBCBS STATE LICENSE
P33590010Medicare PIN