Provider Demographics
NPI:1780269340
Name:SHANE, ADRIENNE CHABOT (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ADRIENNE
Middle Name:CHABOT
Last Name:SHANE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:
Other - Last Name:CHABOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7315 WINTER VIEW DR SW
Mailing Address - Street 2:
Mailing Address - City:BYRON CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49315-6943
Mailing Address - Country:US
Mailing Address - Phone:574-210-9612
Mailing Address - Fax:
Practice Address - Street 1:7315 WINTER VIEW DR SW
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-6943
Practice Address - Country:US
Practice Address - Phone:574-210-9612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant