Provider Demographics
NPI:1932139367
Name:AHRENS, SHANNON D (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:D
Last Name:AHRENS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:728 W WACKERLY ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-4724
Mailing Address - Country:US
Mailing Address - Phone:989-837-6868
Mailing Address - Fax:989-837-6837
Practice Address - Street 1:728 W WACKERLY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-4724
Practice Address - Country:US
Practice Address - Phone:989-837-6868
Practice Address - Fax:989-837-6837
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP19540001Medicare ID - Type Unspecified
MIQ19516Medicare UPIN