Provider Demographics
NPI:1003993916
Name:SHELLEY, AMANDA E (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:E
Last Name:SHELLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:E
Other - Last Name:SHELLEY-AYALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2196 E WILLIAMS FIELD RD
Mailing Address - Street 2:#116
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-0754
Mailing Address - Country:US
Mailing Address - Phone:480-237-1395
Mailing Address - Fax:602-218-4076
Practice Address - Street 1:2196 E WILLIAMS FIELD RD
Practice Address - Street 2:#116
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-0754
Practice Address - Country:US
Practice Address - Phone:480-237-1395
Practice Address - Fax:602-218-4076
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3264363A00000X
CA52291363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant