Provider Demographics
NPI:1710389853
Name:BLEEKER, SHANTEL LYNN (PA-C, RD)
Entity Type:Individual
Prefix:
First Name:SHANTEL
Middle Name:LYNN
Last Name:BLEEKER
Suffix:
Gender:F
Credentials:PA-C, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3304 COOLEY CT
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-7430
Mailing Address - Country:US
Mailing Address - Phone:269-349-2266
Mailing Address - Fax:269-349-0792
Practice Address - Street 1:3304 COOLEY CT
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024
Practice Address - Country:US
Practice Address - Phone:269-349-2266
Practice Address - Fax:269-349-0792
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007179363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical