Provider Demographics
NPI:1215917836
Name:HANOUTE, SHANAE A (PA C)
Entity type:Individual
Prefix:
First Name:SHANAE
Middle Name:A
Last Name:HANOUTE
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:SHANAE
Other - Middle Name:A
Other - Last Name:JACOBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2600 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4828
Mailing Address - Country:US
Mailing Address - Phone:269-324-4141
Mailing Address - Fax:269-324-2020
Practice Address - Street 1:2600 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4828
Practice Address - Country:US
Practice Address - Phone:269-324-4141
Practice Address - Fax:269-324-2020
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003319363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1215917836Medicaid
MIP14380002Medicare PIN
P46703Medicare UPIN