Basic Information
| Provider Information | |||||||||
| NPI: | 1639538473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHIRLEY | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | BETH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 HIGHWAY 142 | ||||||||
| Address2: | |||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383756635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316457932 | ||||||||
| FaxNumber: | 7316455195 | ||||||||
| Practice Location | |||||||||
| Address1: | 270 E COURT AVE | ||||||||
| Address2: | |||||||||
| City: | SELMER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 383752304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316457932 | ||||||||
| FaxNumber: | 7316455195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2016 | ||||||||
| LastUpdateDate: | 02/22/2016 | ||||||||
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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 | 363A00000X | 2983 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.