Provider Demographics
NPI:1336432764
Name:EISENGRUBER, SHAUN MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:MICHAEL
Last Name:EISENGRUBER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3537 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7941
Mailing Address - Country:US
Mailing Address - Phone:231-395-5880
Mailing Address - Fax:231-935-3464
Practice Address - Street 1:3537 W FRONT ST STE E
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-7943
Practice Address - Country:US
Practice Address - Phone:231-935-5880
Practice Address - Fax:231-935-3464
Is Sole Proprietor?:No
Enumeration Date:2011-05-18
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601007080363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical