Provider Demographics
NPI:1679195176
Name:DIGNAN, SHANE MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:MICHAEL
Last Name:DIGNAN
Suffix:
Gender:M
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 1:25509 KELLY RD STE A
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-5823
Mailing Address - Country:US
Mailing Address - Phone:586-252-2616
Mailing Address - Fax:313-563-8443
Practice Address - Street 1:25509 KELLY RD STE A
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5823
Practice Address - Country:US
Practice Address - Phone:586-252-2616
Practice Address - Fax:313-563-8443
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
MI363AM0700X
MI5601009967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical