Provider Demographics
NPI:1780053439
Name:KLIMKOWSKI, SHANNON KASEY (PA)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:KASEY
Last Name:KLIMKOWSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:KASEY
Other - Last Name:KLIMKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26901 BEAUMONT BLVD STE 3D
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:44201 DEQUINDRE RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1117
Practice Address - Country:US
Practice Address - Phone:248-964-8912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-23
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007478363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant