Provider Demographics
NPI:1114336120
Name:WILSON, SHELBY (PA-C)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
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 1:18205 N 51ST AVE
Mailing Address - Street 2:SUITE 129
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1490
Mailing Address - Country:US
Mailing Address - Phone:623-398-8554
Mailing Address - Fax:623-398-8278
Practice Address - Street 1:18205 N 51ST AVE
Practice Address - Street 2:SUITE 129
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-1490
Practice Address - Country:US
Practice Address - Phone:623-398-8554
Practice Address - Fax:623-398-8278
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5768363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant