Provider Demographics
NPI:1013938232
Name:SHORTER, DONNA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
Last Name:SHORTER
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 1:1233 34TH ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5112
Mailing Address - Country:US
Mailing Address - Phone:218-333-5000
Mailing Address - Fax:218-759-5024
Practice Address - Street 1:1233 34TH ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5112
Practice Address - Country:US
Practice Address - Phone:218-333-5000
Practice Address - Fax:218-759-5024
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9059363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN301521100Medicaid
MN301521100Medicaid
MN970000191Medicare PIN