Provider Demographics
NPI:1316535636
Name:MAKRIS, SHELBY NICHOLE (PA)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:NICHOLE
Last Name:MAKRIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12998 HESPERIA RD STE 204
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-8317
Mailing Address - Country:US
Mailing Address - Phone:760-780-4960
Mailing Address - Fax:
Practice Address - Street 1:12998 HESPERIA RD STE 204
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8317
Practice Address - Country:US
Practice Address - Phone:760-780-4960
Practice Address - Fax:760-780-4964
Is Sole Proprietor?:No
Enumeration Date:2021-01-03
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59583363A00000X
174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant