Basic Information
| Provider Information | |||||||||
| NPI: | 1467491258 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHALBY | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | JAYNE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 550 E WASHINGTON BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955318160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078266633 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 E WASHINGTON BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CRESCENT CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955318160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 04/10/2017 | ||||||||
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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 | 363AM0700X | 1646 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 1500388 | KS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 15-00388 | 01 | KS | KS STATE BOARD OF HEALING ARTS | OTHER | 1646 | 01 | OK | OKLAHOMA STATE BOARD OF M | OTHER |