Provider Demographics
NPI:1316772866
Name:SHANGO, KRISTINE (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:SHANGO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7454 TIMBERS EDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3335
Mailing Address - Country:US
Mailing Address - Phone:248-866-9098
Mailing Address - Fax:
Practice Address - Street 1:811 SOUTH BLVD E STE 200
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5359
Practice Address - Country:US
Practice Address - Phone:248-651-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-04
Last Update Date:2024-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012712363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant