Provider Demographics
NPI:1760642557
Name:SHANLEY, BARBARA KINGSLEY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BARBARA
Middle Name:KINGSLEY
Last Name:SHANLEY
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 1:24250 PARKE LN
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1704
Mailing Address - Country:US
Mailing Address - Phone:734-250-4206
Mailing Address - Fax:
Practice Address - Street 1:24250 PARKE LN
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-1704
Practice Address - Country:US
Practice Address - Phone:734-250-4206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-15
Last Update Date:2008-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant