Provider Demographics
NPI:1275779480
Name:SHELTON, MARVIN MITCH (CRNP)
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:MITCH
Last Name:SHELTON
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2190
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35403-2190
Mailing Address - Country:US
Mailing Address - Phone:205-562-3700
Mailing Address - Fax:205-562-3769
Practice Address - Street 1:3701 LOOP RD
Practice Address - Street 2:BLDG 39
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5015
Practice Address - Country:US
Practice Address - Phone:205-562-3700
Practice Address - Fax:205-562-3769
Is Sole Proprietor?:No
Enumeration Date:2008-12-18
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-043069363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner