Provider Demographics
NPI:1063859544
Name:SHELTON, JONATHAN RICHARD (PA)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:RICHARD
Last Name:SHELTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1787 W LEE HWY
Mailing Address - Street 2:
Mailing Address - City:WYTHEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24382-1437
Mailing Address - Country:US
Mailing Address - Phone:276-227-0967
Mailing Address - Fax:276-227-0956
Practice Address - Street 1:1787 W LEE HWY
Practice Address - Street 2:
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382-1437
Practice Address - Country:US
Practice Address - Phone:276-227-0967
Practice Address - Fax:276-227-0956
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004242363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1063859544Medicaid
VA1063859544Medicaid