Provider Demographics
NPI:1689985228
Name:SNIDER, SHANNON GABRIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:GABRIELLE
Last Name:SNIDER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:GABRIELLE
Other - Last Name:DUTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3434 M 119 STE C
Mailing Address - Street 2:
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9373
Mailing Address - Country:US
Mailing Address - Phone:231-348-9900
Mailing Address - Fax:
Practice Address - Street 1:3434 M 119 STE C
Practice Address - Street 2:
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-9373
Practice Address - Country:US
Practice Address - Phone:231-348-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005686363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005686OtherLICENSE #