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General NPI Number Information
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NPI Number | 1679195176
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Entity Type | Individual
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Provider Name | SHANE MICHAEL DIGNAN PA-C
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Gender | Male
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Dates
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Enumeration Date | 05/07/2020
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Last Update Date | 09/15/2022
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Provider Practice Location Address
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Address Line | 25509 KELLY RD STE A
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City | ROSEVILLE
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State | MI
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Zip | 48066-5823
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Country | US
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Telephone | 586-252-2616
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Fax | 313-563-8443
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Provider Business Mailing Address
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Address Line | 25509 KELLY RD STE A
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City | ROSEVILLE
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State | MI
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Zip | 48066-5823
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Country | US
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Telephone | 586-252-2616
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Fax | 313-563-8443
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 5601009967
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License Number State | MI
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