Provider Demographics
NPI:1891263406
Name:SHANNON, RYAN MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:MICHAEL
Last Name:SHANNON
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 1:6534 CONESTOGA DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-9652
Mailing Address - Country:US
Mailing Address - Phone:517-927-4383
Mailing Address - Fax:
Practice Address - Street 1:1280 E CAMPUS DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-3803
Practice Address - Country:US
Practice Address - Phone:989-774-2478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant