Basic Information
| Provider Information | |||||||||
| NPI: | 1003993916 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELLEY | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHELLEY-AYALA | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | E | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2196 E WILLIAMS FIELD RD | ||||||||
| Address2: | #116 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852950754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802371395 | ||||||||
| FaxNumber: | 6022184076 | ||||||||
| Practice Location | |||||||||
| Address1: | 2196 E WILLIAMS FIELD RD | ||||||||
| Address2: | #116 | ||||||||
| City: | GILBERT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852950754 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802371395 | ||||||||
| FaxNumber: | 6022184076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 11/04/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3264 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 52291 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.