Provider Demographics
NPI:1932194214
Name:SANDERS, SHIRLEY E (PAC)
Entity Type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:E
Last Name:SANDERS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:555 RAILROAD STREET
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-0069
Mailing Address - Country:US
Mailing Address - Phone:269-427-6171
Mailing Address - Fax:866-242-4929
Practice Address - Street 1:555 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1464
Practice Address - Country:US
Practice Address - Phone:269-427-6171
Practice Address - Fax:866-242-4929
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIC96055013Medicare PIN