Basic Information
| Provider Information | |||||||||
| NPI: | 1124251103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHELTON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | TYSHUNE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, MSN | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 COMMERCIAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782213117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109227000 | ||||||||
| FaxNumber: | 2102270282 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 N SAN SABA STE 1075 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109227000 | ||||||||
| FaxNumber: | 2102270282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2009 | ||||||||
| LastUpdateDate: | 05/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN 794786 | TX | N | Nursing Service Providers | Registered Nurse | 363LF0000X | F1009375 NP-C | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.