Provider Demographics
NPI:1053879411
Name:BIGTACION, SHALLYMAR (NP)
Entity type:Individual
Prefix:
First Name:SHALLYMAR
Middle Name:
Last Name:BIGTACION
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 S MAIN ST STE 101B
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-3082
Mailing Address - Country:US
Mailing Address - Phone:810-969-4500
Mailing Address - Fax:
Practice Address - Street 1:700 S MAIN ST STE 101B
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3082
Practice Address - Country:US
Practice Address - Phone:810-969-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-05
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704248976363LF0000X
MI4704248973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily