Provider Demographics
NPI:1073063772
Name:SHELTON, BEAU J (PA-C)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:J
Last Name:SHELTON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY OF NEW MEXICO # 105600
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-272-4107
Mailing Address - Fax:505-272-8098
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO # 105600
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-272-4107
Practice Address - Fax:505-272-8098
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA180086363A00000X
NMPA2018-0087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant