Healthcare Provider Details

I. General information

NPI: 1639618747
Provider Name (Legal Business Name): PATRICK LAMAR SHIELDS CNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1492 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4336
US

IV. Provider business mailing address

1492 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4336
US

V. Phone/Fax

Practice location:
  • Phone: 231-730-2435
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number432676488260
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: