Provider Demographics
NPI:1043411523
Name:SHELLEY, BRANDON CHAD (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:CHAD
Last Name:SHELLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 FOOTHILL BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4771
Mailing Address - Country:US
Mailing Address - Phone:307-362-9545
Mailing Address - Fax:307-362-9732
Practice Address - Street 1:2631 FOOTHILL BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4771
Practice Address - Country:US
Practice Address - Phone:307-362-9545
Practice Address - Fax:307-362-9732
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007005956213ES0103X, 213E00000X
SD218213ES0103X, 213E00000X
WY145213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO35666011OtherBC/BS OF KANSAS
MO5648250001OtherNORDIAN ADMINISTRATIVE
SDS107813Medicare UPIN
MO35666011OtherBC/BS OF KANSAS