Provider Demographics
NPI:1750717328
Name:WILLS-VELEZ, SHANNON M (PHD, MS, PA-C)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:M
Last Name:WILLS-VELEZ
Suffix:
Gender:F
Credentials:PHD, MS, PA-C
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:M
Other - Last Name:WILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3577 W 13 MILE RD
Mailing Address - Street 2:STE 404
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6710
Mailing Address - Country:US
Mailing Address - Phone:248-551-6900
Mailing Address - Fax:248-551-6909
Practice Address - Street 1:3577 W 13 MILE RD
Practice Address - Street 2:STE 404
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6710
Practice Address - Country:US
Practice Address - Phone:248-551-6900
Practice Address - Fax:248-551-6909
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006762363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F37131Medicare PIN