Provider Demographics
NPI:1063393718
Name:PAVLAK, SHANNON
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:PAVLAK
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 ROBINDALE AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1014
Mailing Address - Country:US
Mailing Address - Phone:313-433-2354
Mailing Address - Fax:
Practice Address - Street 1:909 WILSON RD
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48824-6410
Practice Address - Country:US
Practice Address - Phone:517-353-2460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant