Provider Demographics
NPI:1972577583
Name:SHANK, HOLLY J (PA C)
Entity type:Individual
Prefix:MS
First Name:HOLLY
Middle Name:J
Last Name:SHANK
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:HOLLY
Other - Middle Name:
Other - Last Name:GATCHEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5900 BYRON CENTER AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-9606
Mailing Address - Country:US
Mailing Address - Phone:616-252-3243
Mailing Address - Fax:616-252-0260
Practice Address - Street 1:2221 HEALTH DR SW STE 2100
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-9650
Practice Address - Country:US
Practice Address - Phone:616-252-4100
Practice Address - Fax:616-252-4480
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003909363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI970030440OtherRAILROAD MEDICARE
MI970030440OtherRAILROAD MEDICARE
MI0N61590Medicare PIN