Provider Demographics
NPI:1912246513
Name:SHULLICK, MATTHEW JOHN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:SHULLICK
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:
Other - Last Name:SHULLICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:3001 NEWBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:NEWBERRY
Mailing Address - State:MI
Mailing Address - Zip Code:49868-1340
Mailing Address - Country:US
Mailing Address - Phone:906-293-6200
Mailing Address - Fax:
Practice Address - Street 1:3001 NEWBERRY AVE
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:MI
Practice Address - Zip Code:49868-1340
Practice Address - Country:US
Practice Address - Phone:906-293-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704277940363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily