Provider Demographics
NPI:1033115480
Name:SHEDELBOWER, JAMIE LYNN (PA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:SHEDELBOWER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYNN
Other - Last Name:SWANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:915 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63106-1621
Mailing Address - Country:US
Mailing Address - Phone:314-289-6376
Mailing Address - Fax:
Practice Address - Street 1:915 N GRAND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63106-1621
Practice Address - Country:US
Practice Address - Phone:314-289-6376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK11685Medicare ID - Type Unspecified
ILQ27147Medicare UPIN