Provider Demographics
NPI:1326031253
Name:ELSE, SHELLY RENEE (PA C)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RENEE
Last Name:ELSE
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:SHELLY
Other - Middle Name:RENEE
Other - Last Name:SAUCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA C
Mailing Address - Street 1:300 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ODEBOLT
Mailing Address - State:IA
Mailing Address - Zip Code:51458-7714
Mailing Address - Country:US
Mailing Address - Phone:712-668-2232
Mailing Address - Fax:712-668-2233
Practice Address - Street 1:300 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:ODEBOLT
Practice Address - State:IA
Practice Address - Zip Code:51458-7714
Practice Address - Country:US
Practice Address - Phone:712-668-2232
Practice Address - Fax:712-668-2233
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000938363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S29902Medicare UPIN
55556Medicare ID - Type Unspecified
IA1326031253Medicare PIN