Provider Demographics
NPI:1700989605
Name:SHIVELY, KIRSTEN M (PA)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:M
Last Name:SHIVELY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 3 MILE ROAD NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49544
Mailing Address - Country:US
Mailing Address - Phone:616-785-3883
Mailing Address - Fax:616-785-1982
Practice Address - Street 1:1550 3 MILE RD NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49544-8251
Practice Address - Country:US
Practice Address - Phone:616-785-3883
Practice Address - Fax:616-785-1982
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1598712390OtherGROUP NPI
MI0M80080OtherMEDICARE
MI1649287517OtherGROUP NPI
N80470001Medicare PIN