Basic Information
| Provider Information | |||||||||
| NPI: | 1164455838 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHELBY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2630 HOLME AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191523004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673393500 | ||||||||
| FaxNumber: | 2673393763 | ||||||||
| Practice Location | |||||||||
| Address1: | 2630 HOLME AVE | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191523004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2673393500 | ||||||||
| FaxNumber: | 2673393763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 05/13/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | MA052311 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.