Provider Demographics
NPI:1790006682
Name:WEBSTER, SHANNON KIRSTEN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:SHANNON
Middle Name:KIRSTEN
Last Name:WEBSTER
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 1:911 E 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-1934
Mailing Address - Country:US
Mailing Address - Phone:248-336-4000
Mailing Address - Fax:248-336-9137
Practice Address - Street 1:911 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-1934
Practice Address - Country:US
Practice Address - Phone:248-336-4000
Practice Address - Fax:248-336-9137
Is Sole Proprietor?:No
Enumeration Date:2010-06-15
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005506133V00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2804009Medicare PIN