Provider Demographics
NPI:1649866138
Name:MARDIAN, SHANIA D (PA-C)
Entity type:Individual
Prefix:
First Name:SHANIA
Middle Name:D
Last Name:MARDIAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHANIA
Other - Middle Name:D
Other - Last Name:SHULL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:330 DAKOTA DUNES BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:DAKOTA DUNES
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5462
Mailing Address - Country:US
Mailing Address - Phone:605-422-3000
Mailing Address - Fax:605-422-3001
Practice Address - Street 1:330 DAKOTA DUNES BLVD
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5461
Practice Address - Country:US
Practice Address - Phone:605-422-3000
Practice Address - Fax:605-422-3001
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA105634363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant