Healthcare Provider Details

I. General information

NPI: 1821544123
Provider Name (Legal Business Name): YUAN SHANG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 03/29/2025
Certification Date: 03/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10047 CROSSROAD CT SE
CALEDONIA MI
49316-7316
US

IV. Provider business mailing address

3640 BRIDGEHAMPTON DR NE
GRAND RAPIDS MI
49546-1445
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-8850
  • Fax:
Mailing address:
  • Phone: 877-906-9699
  • Fax: 888-483-0118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704321387
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: