Provider Demographics
NPI:1730471368
Name:SHIELDS, JUSTIN L (PA)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:L
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE MC-845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:616-267-0800
Mailing Address - Fax:616-267-0801
Practice Address - Street 1:25 MICHIGAN ST NE STE 5100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2572
Practice Address - Country:US
Practice Address - Phone:616-267-0800
Practice Address - Fax:616-267-0801
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2015-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006017363A00000X
261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1730471368Medicaid
MI1730471368Medicaid
MIM33350469Medicare PIN