Provider Demographics
NPI:1023043890
Name:SHELTON, PETER D (PA)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:SHELTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:HAMPTON
Other - Middle Name:ORTHOPEDICS
Other - Last Name:SPORTS MEDICINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:GROUP
Mailing Address - Street 1:325 MEETING HOUSE LN BLDG 2
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-5087
Mailing Address - Country:US
Mailing Address - Phone:631-287-9477
Mailing Address - Fax:
Practice Address - Street 1:325 MEETING HOUSE LN BLDG 2
Practice Address - Street 2:SUITE 301
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5087
Practice Address - Country:US
Practice Address - Phone:631-287-9477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000426 1363AS0400X
NY000426 2363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS58075Medicare UPIN
NY0F0031Medicare PIN