Individual provider Active NPI

Selena Shamo

  • Physician Assistant
  • Detroit, MI
National Provider Identifier
1124844014
Registry record updated Jun 18, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
1235097 Issued in MI
Practice address
259 Mack Ave Ste 2590
Detroit, MI 48201-2427
Phone
(313) 577-1716
NPI assigned
Nov 25, 2024
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 18, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 1235097 MI Primary

Addresses

Primary practice location

259 Mack Ave Ste 2590
Detroit, MI 48201-2427

Mailing address

259 Mack Ave Ste 2590
Detroit, MI 48201-2427

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI
Eligible to order & refer
  • Part B services: Yes
  • Medical equipment: Yes
  • Home health: Yes
  • Power mobility devices: Yes
  • Hospice: No
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20250618000861 MI Practitioner - Physician Assistant 1557872314 Reassigns benefits to 1 organization

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled

State licenses

LicenseStateTypeSpecialty
1235097MIMDPhysician Assistant

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1732492800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1750204800000",
    "number": "1124844014",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "259 MACK AVE STE 2590",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482012427"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "259 MACK AVE STE 2590",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482012427",
            "telephone_number": "313-577-1716"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SHAMO",
        "first_name": "SELENA",
        "name_prefix": "Ms.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-11-25",
        "last_updated": "2025-06-18",
        "certification_date": "2025-06-18",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "MI",
            "license": "1235097",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Detroit, MI

Sources for this page

Verify at the official NPI Registry.