Provider Demographics
NPI:1245800937
Name:SHERIDAN, MALLORY JANE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MALLORY
Middle Name:JANE
Last Name:SHERIDAN
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:3021 BIRCH ROW DR APT 14
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-2295
Mailing Address - Country:US
Mailing Address - Phone:231-675-7250
Mailing Address - Fax:
Practice Address - Street 1:416 S CREYTS RD
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8290
Practice Address - Country:US
Practice Address - Phone:517-886-0333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601010628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant