Provider Demographics
NPI:1063789014
Name:BRUNSMAN, SHAWNDELIN MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:SHAWNDELIN
Middle Name:MARIE
Last Name:BRUNSMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHAWNDELIN
Other - Middle Name:MARIE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:28963 LITTLE MACK AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-3017
Mailing Address - Country:US
Mailing Address - Phone:586-447-0228
Mailing Address - Fax:
Practice Address - Street 1:6071 W OUTER DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2624
Practice Address - Country:US
Practice Address - Phone:248-765-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-18
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL2084575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant