Provider Demographics
NPI:1881669224
Name:TODD, SHANNON J (PAC)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:J
Last Name:TODD
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:JO
Other - Last Name:NEUHALFEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1000 E PARIS AVE SE STE 214
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3680
Mailing Address - Country:US
Mailing Address - Phone:248-546-3991
Mailing Address - Fax:616-828-4831
Practice Address - Street 1:1000 E PARIS AVE SE STE 214
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3680
Practice Address - Country:US
Practice Address - Phone:248-546-3991
Practice Address - Fax:616-828-4831
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002943363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN38550110Medicare PIN
S70515Medicare UPIN
N48650030Medicare PIN
MIM74460306Medicare PIN