Basic Information
| Provider Information | |||||||||
| NPI: | 1912634296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHRADER | ||||||||
| FirstName: | ALLY | ||||||||
| MiddleName: | AJA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CPNP-AC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 11389 SOUTHWORTH AVE | ||||||||
| Address2: | |||||||||
| City: | PLYMOUTH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481704477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482421800 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1540 E HOSPITAL DR RM 12-733 | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481094000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349364179 | ||||||||
| FaxNumber: | 7347637551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2022 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 4704324614 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LP0200X | 4704324614 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.