Healthcare Provider Details

I. General information

NPI: 1932194214
Provider Name (Legal Business Name): SHIRLEY E SANDERS P.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2005
Last Update Date: 08/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 RAILROAD ST
BANGOR MI
49013-1464
US

IV. Provider business mailing address

PO BOX 69 555 RAILROAD STREET
BANGOR MI
49013-0069
US

V. Phone/Fax

Practice location:
  • Phone: 269-427-6171
  • Fax: 866-242-4929
Mailing address:
  • Phone: 269-427-6171
  • Fax: 866-242-4929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001054
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: