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NPI Code Detail

MEDICARE: BETHANY R SHANKU PA-C

MEDICARE: BETHANY R SHANKU PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant0796NH
2363AM0700XMedical Physician Assistant015254NY
3363A00000XPhysician Assistant5601007853MI
4363AM0700XMedical Physician AssistantPA1507TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14158075OTHERTNBC/BS TN - CUMBERLAND BACK PAIN CLINIC, P.C.
24190395OTHERTNBS/BS TN - LEBANON BACK PAIN CLINIC, P.C.
3MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4PA1507OTHERTNSTATE LICENSE

General Provider Information

NPI Number : 1851581573
Entity Type Code : Individual
Provider Name (Legal Business Name) : BETHANY R SHANKU PA-C
Provider Business Mailing Address
First Line : 26211 CENTRAL PARK BLVD STE 201
Second Line :
City : SOUTHFIELD
State : MI
Zip : 48076-4158
Country : US
Telephone Number : 833-667-3627
Fax Number : 248-327-6144
Provider Business Practice Location Address
First Line : 26025 LAHSER RD FL 3
Second Line :
City : SOUTHFIELD
State : MI
Zip : 48033-2606
Country : US
Telephone Number : 248-663-1923
Fax Number : 248-809-3378
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/30/2007
Last Update Date : 04/15/2026

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Directions to “ BETHANY R SHANKU PA-C” Practice Location

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