Provider Demographics
NPI:1164518254
Name:SHELTON, LORI SUMERFORD (PA-C)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:SUMERFORD
Last Name:SHELTON
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 1:457 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:TN
Mailing Address - Zip Code:38583-1360
Mailing Address - Country:US
Mailing Address - Phone:931-738-3383
Mailing Address - Fax:931-738-8911
Practice Address - Street 1:476 SPRING ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:TN
Practice Address - Zip Code:38585-3026
Practice Address - Country:US
Practice Address - Phone:931-946-2113
Practice Address - Fax:931-946-2248
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002308363AS0400X, 363A00000X, 363AM0700X
TN1813363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1164518254Medicaid
TN103I976206Medicare PIN
013963G72Medicare PIN
VA1164518254Medicaid