Provider Demographics
NPI:1295791580
Name:DOHERTY, SHANNON (CRNA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5445 MYRON RD
Mailing Address - Street 2:
Mailing Address - City:GRANT TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48032-2403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30200 TELEGRAPH RD
Practice Address - Street 2:SUITE 220
Practice Address - City:BINGHAM FARMS
Practice Address - State:MI
Practice Address - Zip Code:48025-4502
Practice Address - Country:US
Practice Address - Phone:248-258-5058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704140193367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104838402Medicaid
MIP00311232OtherRAILROAD MEDICARE
MI104838402Medicaid
MIP00311232Medicare PIN
MIP00311232OtherRAILROAD MEDICARE