Basic Information
| Provider Information | |||||||||
| NPI: | 1013990712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DARTY | ||||||||
| FirstName: | SHELLY | ||||||||
| MiddleName: | WARREN | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 IDOL ST | ||||||||
| Address2: | |||||||||
| City: | HIGH POINT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272627804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022400 | ||||||||
| FaxNumber: | 3368022001 | ||||||||
| Practice Location | |||||||||
| Address1: | 861 OLD WINSTON RD | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272847140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368022300 | ||||||||
| FaxNumber: | 3368022301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2005 | ||||||||
| LastUpdateDate: | 05/18/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 102585 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7057773 | 01 | NC | AETNA | OTHER | D7935 | 01 | NC | MEDCOST | OTHER |