Individual
JUSTIN L SHIELDS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
25 MICHIGAN ST NE STE 5100, GRAND RAPIDS, MI 49503-2572
(616) 267-0800
(616) 267-0801
Mailing address
100 MICHIGAN ST NE MC-845, GRAND RAPIDS, MI 49503-2560
(616) 267-0800
(616) 267-0801
Taxonomy
Speciality
Code
Description
License number
State
261QF0400X
Federally Qualified Health Center (FQHC)
—
—
363A00000X
Physician Assistant
Primary
5601006017
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1730471368
—
MI
Enumeration date
05/16/2011
Last updated
10/09/2015
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