Provider Demographics
NPI:1285022095
Name:SHELTON, JAIMIE LEANNE (PA)
Entity Type:Individual
Prefix:
First Name:JAIMIE
Middle Name:LEANNE
Last Name:SHELTON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JAIMIE
Other - Middle Name:LEANNE
Other - Last Name:MCGLOTHLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:245 MEDICAL PARK DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-1100
Mailing Address - Country:US
Mailing Address - Phone:276-378-3300
Mailing Address - Fax:276-378-1265
Practice Address - Street 1:245 MEDICAL PARK DR
Practice Address - Street 2:SUITE C
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-1100
Practice Address - Country:US
Practice Address - Phone:276-378-3300
Practice Address - Fax:276-378-1265
Is Sole Proprietor?:No
Enumeration Date:2014-12-31
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-004707363A00000X
TNPA0000002664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1285022095Medicaid
VAVVG296AMedicare PIN