Provider Demographics
NPI:1164455838
Name:SHELBY, KEVIN A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:A
Last Name:SHELBY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 HOLME AVE
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-3004
Mailing Address - Country:US
Mailing Address - Phone:267-339-3500
Mailing Address - Fax:267-339-3763
Practice Address - Street 1:2630 HOLME AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-3004
Practice Address - Country:US
Practice Address - Phone:267-339-3500
Practice Address - Fax:267-339-3763
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052311363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q71102Medicare UPIN
PA110760GC6Medicare PIN