Provider Demographics
NPI:1679995252
Name:SHOCK, DANIELLA MARIA-BRIKHO (PA-C)
Entity Type:Individual
Prefix:
First Name:DANIELLA
Middle Name:MARIA-BRIKHO
Last Name:SHOCK
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 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:14650 EAST OLD US HIGHWAY 12
Practice Address - Street 2:SUITE 306
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118
Practice Address - Country:US
Practice Address - Phone:734-475-4003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008334363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant